Provider Demographics
NPI:1720743651
Name:BEACH, SALLY MICHELLE
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:MICHELLE
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 1:14957 E DANCER CIR
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-7784
Mailing Address - Country:US
Mailing Address - Phone:907-229-2194
Mailing Address - Fax:
Practice Address - Street 1:5630 B ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-1641
Practice Address - Country:US
Practice Address - Phone:907-441-8559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11131013146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate