Provider Demographics
NPI:1336612951
Name:BEACH, MARY B
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:BEACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ZINNIAS CT
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5628
Mailing Address - Country:US
Mailing Address - Phone:727-512-7596
Mailing Address - Fax:
Practice Address - Street 1:12 ZINNIAS CT
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5628
Practice Address - Country:US
Practice Address - Phone:727-560-8780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1059541164W00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No164W00000XNursing Service ProvidersLicensed Practical Nurse