Provider Demographics
NPI:1275132136
Name:PECK, TINA (APRN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 N ROCK RD # 118-266
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2331
Mailing Address - Country:US
Mailing Address - Phone:316-708-4099
Mailing Address - Fax:
Practice Address - Street 1:430 S COMMERCE ST STE 300
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-4600
Practice Address - Country:US
Practice Address - Phone:316-708-4099
Practice Address - Fax:949-209-5494
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-77614363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily