Provider Demographics
NPI:1447785829
Name:PEACOCK, NOLA (PT, DSC)
Entity Type:Individual
Prefix:DR
First Name:NOLA
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:PT, DSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11124
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1124
Mailing Address - Country:US
Mailing Address - Phone:307-739-7628
Mailing Address - Fax:
Practice Address - Street 1:555 E BROADWAY AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-7628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-0665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist