Basic Information
| Provider Information | |||||||||
| NPI: | 1770624900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | GILLIAM | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N EAGLE CREEK DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592592635 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 151 N EAGLE CREEK DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592592635 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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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 | 1043709 | KY | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 3005386 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7100137110 | 05 | KY | MEDICAID | 30615058 | 05 | KY | MEDICAID | 31001118 | 05 | KY | MEDICAID |