Provider Demographics
NPI:1710393830
Name:BEAVER, KRISTINE
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:BEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:INGER
Other - Middle Name:
Other - Last Name:LAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:730 EAST 500 SOUTH
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511
Mailing Address - Country:US
Mailing Address - Phone:435-773-3988
Mailing Address - Fax:
Practice Address - Street 1:730 EAST 500 SOUTH
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511
Practice Address - Country:US
Practice Address - Phone:435-773-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT364787915364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health