Provider Demographics
NPI:1548505464
Name:BEAVERS, SALLY (RN)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-0434
Mailing Address - Country:US
Mailing Address - Phone:541-469-0405
Mailing Address - Fax:
Practice Address - Street 1:29984 ELLENSBURG AVE
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444
Practice Address - Country:US
Practice Address - Phone:541-469-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200842276RN163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care