Provider Demographics
NPI:1407382864
Name:PEACOCK, CARLIE LAYNE (NP)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:LAYNE
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 1:301 BROWN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7005
Mailing Address - Country:US
Mailing Address - Phone:334-747-4159
Mailing Address - Fax:
Practice Address - Street 1:2055 E SOUTH BLVD STE 601
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2014
Practice Address - Country:US
Practice Address - Phone:334-747-2999
Practice Address - Fax:334-747-7276
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-137124363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL512-04310OtherBCBS OF ALABAMA
ALA0001K874OtherMEDICARE
AL212224Medicaid
AL512-04312OtherBCBS OF ALABAMA
ALZ54221OtherVIVA HEALTH