Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 209016345 | IL |
NPI | 1003325952 |
---|---|
Provider Name | Kelsey Beasley |
First Address | Belleville, IL 62221-7044 |
Second Address | Belleville, IL 62221-7044 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2017 |
Last Update Date | 22/09/2017 |