Provider Demographics
NPI:1992264626
Name:BEALL, CASSIDY CONNETT (NP)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:CONNETT
Last Name:BEALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CASSIDY
Other - Middle Name:MARIE
Other - Last Name:CONNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-617-6705
Mailing Address - Fax:
Practice Address - Street 1:1124 GALLERY PARK BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-1142
Practice Address - Country:US
Practice Address - Phone:910-343-1031
Practice Address - Fax:910-251-8896
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0994155-NP363LF0000X
NC15743457363LF0000X
NC5017110363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000171155Medicaid