Basic Information
| Provider Information | |||||||||
| NPI: | 1750579967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REILLY | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | ANP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 84068 | ||||||||
| Address2: | SENIOR HEALTH ASSOCIATES | ||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437571173 | ||||||||
| FaxNumber: | 8665270937 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 PLEASANT POINT DR | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299071164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437571173 | ||||||||
| FaxNumber: | 8665270937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 07/15/2013 | ||||||||
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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 | 363LA2200X | 4704231115 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 18184 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | NP2334 | 05 | SC | MEDICAID |