Basic Information
| Provider Information | |||||||||
| NPI: | 1346548872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYMAN | ||||||||
| FirstName: | BEVERLEY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 ROCHE BROS WAY | ||||||||
| Address2: | |||||||||
| City: | NORTH EASTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023561032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088948730 | ||||||||
| FaxNumber: | 5088948732 | ||||||||
| Practice Location | |||||||||
| Address1: | 18385 LINGERLON AVE | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339483317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522759826 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9172583 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APRN9172583 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | RN-TEMP12962 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | Y06X7 | 01 | FLORIDA BUE-BCBSFL | OTHER | 003409900 | 05 | FL | MEDICAID |