Provider Demographics
NPI:1699051235
Name:BEACH, MARY (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BEACH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WILLOW PARK DR E
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-1145
Mailing Address - Country:US
Mailing Address - Phone:607-749-6368
Mailing Address - Fax:
Practice Address - Street 1:11 KENNEDY PKWY
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1409
Practice Address - Country:US
Practice Address - Phone:607-753-9105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307347163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice