Provider Demographics
NPI:1053556621
Name:BEAUDRY, JOAN
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:BEAUDRY
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 1:6601 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34951-5202
Mailing Address - Country:US
Mailing Address - Phone:772-408-2414
Mailing Address - Fax:
Practice Address - Street 1:755 27TH AVE SW STE 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32968-4209
Practice Address - Country:US
Practice Address - Phone:772-567-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 54497225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist