Provider Demographics
NPI:1477265411
Name:STAFFORD, PEGGY L
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:L
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 VIRGINIA ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2835
Mailing Address - Country:US
Mailing Address - Phone:681-313-4759
Mailing Address - Fax:
Practice Address - Street 1:253 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:SHADY SPRING
Practice Address - State:WV
Practice Address - Zip Code:25918-8454
Practice Address - Country:US
Practice Address - Phone:304-557-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27310164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1487758710Medicaid