Provider Demographics
NPI:1306114970
Name:BEASLEY, AUDREY LOUISE
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LOUISE
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:AUDREY
Other - Middle Name:LOUISE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1897 TUNDRA WAY
Mailing Address - Street 2:P.O. BOX 189
Mailing Address - City:NOORVIK
Mailing Address - State:AK
Mailing Address - Zip Code:99763
Mailing Address - Country:US
Mailing Address - Phone:907-636-2103
Mailing Address - Fax:907-636-2195
Practice Address - Street 1:1897 TUNDRA WAY
Practice Address - Street 2:
Practice Address - City:NOORVIK
Practice Address - State:AK
Practice Address - Zip Code:99763
Practice Address - Country:US
Practice Address - Phone:907-636-2103
Practice Address - Fax:907-636-2195
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10-1092-II42ALASKA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker