Provider Demographics
NPI:1811690183
Name:BEVERLY, MICHELLE LYNN (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3013
Mailing Address - Country:US
Mailing Address - Phone:860-610-6155
Mailing Address - Fax:
Practice Address - Street 1:150 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2086
Practice Address - Country:US
Practice Address - Phone:860-528-1359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11808363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily