Provider Demographics
NPI:1326669367
Name:PEACE, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:PEACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9550 MIDLOTHIAN TPKE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4900
Mailing Address - Country:US
Mailing Address - Phone:803-323-4040
Mailing Address - Fax:804-323-3787
Practice Address - Street 1:9550 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4900
Practice Address - Country:US
Practice Address - Phone:803-323-4040
Practice Address - Fax:804-323-3787
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12022109581744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management