Provider Demographics
NPI:1316599889
Name:PECK, MIRANDA KORRIN (LPN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:KORRIN
Last Name:PECK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 FOX ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NY
Mailing Address - Zip Code:13838-1530
Mailing Address - Country:US
Mailing Address - Phone:607-434-4209
Mailing Address - Fax:
Practice Address - Street 1:101 FOX ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NY
Practice Address - Zip Code:13838-1530
Practice Address - Country:US
Practice Address - Phone:607-434-4209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329267164W00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No164W00000XNursing Service ProvidersLicensed Practical Nurse