Provider Demographics
NPI:1992169270
Name:BEAUVAIS, JENNIFER DIANE (NP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DIANE
Last Name:BEAUVAIS
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 1:947 150TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALSAM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54810
Mailing Address - Country:US
Mailing Address - Phone:715-554-0595
Mailing Address - Fax:
Practice Address - Street 1:235 E STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-4117
Practice Address - Country:US
Practice Address - Phone:715-554-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6853363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner