Provider Demographics
NPI:1386631455
Name:PEACOCK, MARIANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3258
Mailing Address - Country:US
Mailing Address - Phone:231-935-0550
Mailing Address - Fax:231-935-0551
Practice Address - Street 1:1115 S UNION ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3258
Practice Address - Country:US
Practice Address - Phone:231-935-0550
Practice Address - Fax:231-935-0551
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704219432363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08774010OtherBCBS OF MICHIGAN
MI0B81224OtherBCBS OF MICHIGAN
MI1386631455OtherIND NPI
MI0P24620OtherMEDICARE PTAN
MI1245283365OtherGROUP NPI
MI08774010OtherBCBS OF MICHIGAN
MI0N56050Medicare PIN
MIP69997Medicare UPIN