Provider Demographics
NPI:1033296074
Name:MARLATT, PEGGY (LPN, RVT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:MARLATT
Suffix:
Gender:F
Credentials:LPN, RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 E DAVID DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4730
Mailing Address - Country:US
Mailing Address - Phone:928-853-5795
Mailing Address - Fax:
Practice Address - Street 1:1215 N BEAVER ST STE 202
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3126
Practice Address - Country:US
Practice Address - Phone:928-773-2200
Practice Address - Fax:928-773-2201
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18794164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse