Basic Information
| Provider Information | |||||||||
| NPI: | 1871957696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEACH | ||||||||
| FirstName: | SHAYLEA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D. O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIDDLE SHEBESTER | ||||||||
| OtherFirstName: | SHAYLEA | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 E ROBINSON ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055151935 | ||||||||
| FaxNumber: | 4053104311 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 E ROBINSON ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055151935 | ||||||||
| FaxNumber: | 4053104311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2016 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 6254 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.