Provider Demographics
NPI:1235612706
Name:PALMER, PEACHES (NP)
Entity Type:Individual
Prefix:
First Name:PEACHES
Middle Name:
Last Name:PALMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 DARIUS DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2700
Mailing Address - Country:US
Mailing Address - Phone:228-380-2059
Mailing Address - Fax:
Practice Address - Street 1:3661 SANGANI BLVD STE E
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-8707
Practice Address - Country:US
Practice Address - Phone:228-354-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF06180040363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner