Provider Demographics
NPI:1467504084
Name:SMITH, PEGGY ANN (ARNP)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 BRIDGEPORT WAY W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4315
Mailing Address - Country:US
Mailing Address - Phone:253-564-4157
Mailing Address - Fax:253-220-2491
Practice Address - Street 1:4114 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4315
Practice Address - Country:US
Practice Address - Phone:253-564-4157
Practice Address - Fax:253-220-2491
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006974363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARN00138953OtherREGISTARED NURSE LICENSE
20040025-22OtherFAMILY NURSE PRACTITIONER
WAAP30006974OtherARNP LICENSE NUMBER
WAMS1273058OtherDEA REGISTARATION NUMBER