Provider Demographics
NPI:1306066675
Name:BEATTY, GLORIA (LPN)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:BEATTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TULIP AVENUE
Mailing Address - Street 2:PO BOX 20838
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11002-0838
Mailing Address - Country:US
Mailing Address - Phone:917-862-5215
Mailing Address - Fax:718-347-4643
Practice Address - Street 1:1950 CLOVE RD APT 636
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1642
Practice Address - Country:US
Practice Address - Phone:917-862-5215
Practice Address - Fax:718-347-4643
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125288-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02852142Medicaid