Basic Information
| Provider Information | |||||||||
| NPI: | 1336541259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAUPRE | ||||||||
| FirstName: | BROOKLYN | ||||||||
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| Credential: | AG-ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 01/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 19186 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 1336541259 | 05 | VA | MEDICAID | 7100327340 | 05 | KY | MEDICAID | 1336541259 | 05 | NC | MEDICAID | Q009458 | 05 | TN | MEDICAID |