Basic Information
| Provider Information | |||||||||
| NPI: | 1912497058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEATY | ||||||||
| FirstName: | REBEKAH | ||||||||
| MiddleName: | KAYLENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERRY | ||||||||
| OtherFirstName: | BECKY | ||||||||
| OtherMiddleName: | KAYLENE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1645 N DOE VALLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123615215 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8163 W STATE ROAD 56 STE A | ||||||||
| Address2: | |||||||||
| City: | WEST BADEN SPRINGS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474697706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129362425 | ||||||||
| FaxNumber: | 8129362599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71008104A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 300022582 | 05 | IN | MEDICAID |