Provider Demographics
NPI:1275749863
Name:PECK, KATHLEEN MARIE (PHN)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:PECK
Suffix:
Gender:F
Credentials:PHN
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:STANTON
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHN
Mailing Address - Street 1:615 OAKHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-4029
Mailing Address - Country:US
Mailing Address - Phone:530-888-8745
Mailing Address - Fax:
Practice Address - Street 1:11670 ATWOOD RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-9522
Practice Address - Country:US
Practice Address - Phone:530-887-2800
Practice Address - Fax:530-887-2202
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA153753163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator