Provider Demographics
NPI:1508859943
Name:LEGAN, PEGGY L (ANP)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:L
Last Name:LEGAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:CENTER FOR WOUND HEALING
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-684-1035
Mailing Address - Fax:618-687-1155
Practice Address - Street 1:6 E SHAWNEE DR
Practice Address - Street 2:CENTER FOR WOUND HEALING
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-7048
Practice Address - Country:US
Practice Address - Phone:618-684-1035
Practice Address - Fax:618-687-1155
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209001092363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification
IL211097Medicare ID - Type UnspecifiedMEDICARE GROUP
ILPO1551Medicare UPIN