Provider Demographics
NPI:1447735618
Name:CLARK-HOLDEN, PEGGY SUE (RN BSN)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:CLARK-HOLDEN
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 OLD MILL CIR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-6125
Mailing Address - Country:US
Mailing Address - Phone:972-467-4559
Mailing Address - Fax:
Practice Address - Street 1:1004 OLD MILL CIR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-6125
Practice Address - Country:US
Practice Address - Phone:972-467-4559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX855933163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice