Provider Demographics
NPI:1649502568
Name:TIMOTHY, BEVERLY
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:TIMOTHY
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 1:86 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-1251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9704 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-4721
Practice Address - Country:US
Practice Address - Phone:718-657-7088
Practice Address - Fax:718-657-7092
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302799363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331009Medicare Oscar/Certification
NYG100000410Medicare Oscar/Certification
NY00695941Medicaid
NY331943Medicare Oscar/Certification
NY331058Medicare Oscar/Certification