Provider Demographics
NPI:1134299100
Name:SCHUELKE, PEGGY JO (RN, MS, CNP)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:JO
Last Name:SCHUELKE
Suffix:
Gender:F
Credentials:RN, MS, CNP
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:JO
Other - Last Name:FORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MS, CNP
Mailing Address - Street 1:15754 483RD AVE
Mailing Address - Street 2:
Mailing Address - City:REVILLO
Mailing Address - State:SD
Mailing Address - Zip Code:57259-6311
Mailing Address - Country:US
Mailing Address - Phone:605-623-4228
Mailing Address - Fax:605-623-4318
Practice Address - Street 1:103 E. THIRD STREET
Practice Address - Street 2:
Practice Address - City:REVILLO
Practice Address - State:SD
Practice Address - Zip Code:57259
Practice Address - Country:US
Practice Address - Phone:605-623-4695
Practice Address - Fax:605-623-4318
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR02538Medicare UPIN