Provider Demographics
NPI:1407930142
Name:PERDUE, PEGGY L (RN, MA)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:L
Last Name:PERDUE
Suffix:
Gender:F
Credentials:RN, MA
Other - Prefix:MS
Other - First Name:PEGGY
Other - Middle Name:L
Other - Last Name:CASDORPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MA
Mailing Address - Street 1:600 TRACY WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1262
Mailing Address - Country:US
Mailing Address - Phone:304-388-4965
Mailing Address - Fax:304-343-4850
Practice Address - Street 1:600 TRACY WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1223
Practice Address - Country:US
Practice Address - Phone:304-388-2964
Practice Address - Fax:304-399-4968
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV782103T00000X
WV40151163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004165Medicaid
WV001782254OtherMOUNTAIN STATE BC/BS