Provider Demographics
NPI:1386747343
Name:BEAVERS, LAURIE JEAN (FAMILY NURSE PRACTIT)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:JEAN
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:JEAN
Other - Last Name:GEHM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP, CPNP
Mailing Address - Street 1:RR 1 BOX 130
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62044
Mailing Address - Country:US
Mailing Address - Phone:217-368-3001
Mailing Address - Fax:
Practice Address - Street 1:8590 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-8398
Practice Address - Country:US
Practice Address - Phone:217-323-2242
Practice Address - Fax:217-452-7245
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209 000817363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370661499007Medicaid
IL14 8920Medicare ID - Type Unspecified