Basic Information
| Provider Information | |||||||||
| NPI: | 1649502568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIMOTHY | ||||||||
| FirstName: | BEVERLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 86 COLONIAL AVE | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115201251 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9704 SUTPHIN BLVD | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114354721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186577088 | ||||||||
| FaxNumber: | 7186577092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2010 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
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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 | 363LA2200X | 302799 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 00695941 | 05 | NY | MEDICAID |