Provider Demographics
NPI:1265500573
Name:PECK, DENISE A (ARNP)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:A
Last Name:PECK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-947-4498
Mailing Address - Fax:
Practice Address - Street 1:4101 LOMO ALTO DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-1516
Practice Address - Country:US
Practice Address - Phone:214-559-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP1057134363L00000X, 363L00000X
IAA093979363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA71356OtherWELLMARK BCBS
IA1265500573Medicaid
IA1265500573Medicaid
IAI21681Medicare PIN