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: | |
Other - Suffix: | |
Other - Last Name Type: | |
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: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 209001092 | 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 214881 | Medicare Oscar/Certification | |
IL | 211097 | Medicare ID - Type Unspecified | MEDICARE GROUP |
IL | PO1551 | Medicare UPIN |