Provider Demographics
NPI:1770624900
Name:HART, BEVERLY GILLIAM (RN, PHD)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:GILLIAM
Last Name:HART
Suffix:
Gender:F
Credentials:RN, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N EAGLE CREEK DR STE 220
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1892
Mailing Address - Country:US
Mailing Address - Phone:859-259-2635
Mailing Address - Fax:
Practice Address - Street 1:151 N EAGLE CREEK DR STE 220
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1892
Practice Address - Country:US
Practice Address - Phone:859-259-2635
Practice Address - Fax:859-254-7874
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1043709163W00000X
KY3005386363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100137110Medicaid
KY30615058Medicaid
KY31001118Medicaid
KY8558Medicare ID - Type UnspecifiedMEDICARE
KY181870Medicare PIN
KY7100137110Medicaid