Provider Demographics
NPI:1447909601
Name:GIPSON, BEVERLY T (APRN)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:T
Last Name:GIPSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3318
Mailing Address - Country:US
Mailing Address - Phone:573-686-4151
Mailing Address - Fax:
Practice Address - Street 1:711 SOUTH MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-686-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022004857163WP0808X, 2084P0800X
IAG167934363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry