Basic Information
| Provider Information | |||||||||
| NPI: | 1679652481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECK | ||||||||
| FirstName: | JUANITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56549 S 280 AVE | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686383314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3085362570 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2121 N WEBB RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688031751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3083982600 | ||||||||
| FaxNumber: | 3083982633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 8476 | NE | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 47037660130 | 05 | NE | MEDICAID |