Provider Demographics
NPI:1043345804
Name:PALK, PEGGY
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:
Last Name:PALK
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 1:3876 OLD GAINESBORO RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:38545-4512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W 10TH ST
Practice Address - Street 2:TN DEPT OF HEALTH
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-6077
Practice Address - Country:US
Practice Address - Phone:931-528-7531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40408163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse