Provider Demographics
NPI:1417284373
Name:PEAVY, KIRSTI NICOLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:KIRSTI
Middle Name:NICOLE
Last Name:PEAVY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 URBANDALE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3325
Mailing Address - Country:US
Mailing Address - Phone:318-349-8179
Mailing Address - Fax:
Practice Address - Street 1:2551 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3981
Practice Address - Country:US
Practice Address - Phone:318-212-8424
Practice Address - Fax:318-212-8459
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200315363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical