Provider Demographics
NPI:1063473544
Name:PECK, PATTI JO (NP)
Entity Type:Individual
Prefix:MRS
First Name:PATTI
Middle Name:JO
Last Name:PECK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:PATTI
Other - Middle Name:JO
Other - Last Name:DYKEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 221
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:200 JEFFERSON SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-5000
Practice Address - Fax:616-685-3084
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1494303363LN0000X
MI4704151401363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal