Provider Demographics
NPI:1003699505
Name:PEACOCK, CASSIE
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:
Last Name:PEACOCK
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 1:3316 INDIAN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8728
Mailing Address - Country:US
Mailing Address - Phone:850-261-4917
Mailing Address - Fax:
Practice Address - Street 1:3316 INDIAN HILLS DR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8728
Practice Address - Country:US
Practice Address - Phone:850-261-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026951208D00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice