Provider Demographics
NPI:1003268897
Name:PEACH, SANDRA L (APN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:PEACH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3105
Mailing Address - Country:US
Mailing Address - Phone:309-655-2343
Mailing Address - Fax:309-655-3948
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3105
Practice Address - Country:US
Practice Address - Phone:309-655-2343
Practice Address - Fax:309-655-3948
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014408363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner