Provider Demographics
NPI:1477516680
Name:PEACOCK, BARBARA T (FNP)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:T
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:FNP
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 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-537-4986
Mailing Address - Fax:
Practice Address - Street 1:101 HARRIS INDUSTRIAL BLVD
Practice Address - Street 2:STE C
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8852
Practice Address - Country:US
Practice Address - Phone:912-537-1014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR085963363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000845115BMedicaid
GA000845115BMedicaid
GA000845215AMedicaid