Provider Demographics
NPI:1407031982
Name:KLEINLEDER, PEGGY ELLEN (RN)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ELLEN
Last Name:KLEINLEDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7005
Mailing Address - Country:US
Mailing Address - Phone:907-235-0369
Mailing Address - Fax:907-235-0810
Practice Address - Street 1:451 STERLING HWY
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7440
Practice Address - Country:US
Practice Address - Phone:907-235-0369
Practice Address - Fax:907-235-0810
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKRN3704163W00000X
AKCM37041171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG799Medicaid
AKHH2711Medicaid
AKPCG519AMedicaid
AKMS0272Medicaid
AKHC2563Medicaid
AKNA3799Medicaid
AK027010Medicare Oscar/Certification