Basic Information
| Provider Information | |||||||||
| NPI: | 1194258319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEVERLY | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PUGH | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 221 COUNTRY CLUB DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347827757 | ||||||||
| FaxNumber: | 3343839918 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343822681 | ||||||||
| FaxNumber: | 3343839918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2017 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-107936 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.