Provider Demographics
NPI:1699075960
Name:BEASLEY, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:BEASLEY
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 1:5219 CITY BANK PKWY STE 135
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3502 9TH ST
Practice Address - Street 2:SUITE 360
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-3300
Practice Address - Country:US
Practice Address - Phone:806-761-0747
Practice Address - Fax:806-761-0751
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX737829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily