Provider Demographics
NPI:1518294800
Name:PEACOCK, KATHLEEN JO (CNM, RN)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:JO
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:CNM, RN
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:600 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-5432
Mailing Address - Country:US
Mailing Address - Phone:301-807-5605
Mailing Address - Fax:
Practice Address - Street 1:7301 GARLAND AVE
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6417
Practice Address - Country:US
Practice Address - Phone:301-807-5605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR186240367A00000X
DCRN1034066367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife