Provider Demographics
NPI:1194098608
Name:BEAVEN, NICOLE CUTSHAW (CRNA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CUTSHAW
Last Name:BEAVEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:P
Other - Last Name:SAWYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:425 LEWIS HARGETT CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3590
Mailing Address - Country:US
Mailing Address - Phone:859-268-1030
Mailing Address - Fax:859-269-4120
Practice Address - Street 1:310 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-3008
Practice Address - Country:US
Practice Address - Phone:859-252-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22652367500000X
KY3007323367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100193560Medicaid
KYK035530Medicare PIN