Provider Demographics
NPI:1528361318
Name:ALEXIS-PEACOCK, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:ALEXIS-PEACOCK
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 1:10724 155TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-1924
Mailing Address - Country:US
Mailing Address - Phone:347-510-9972
Mailing Address - Fax:
Practice Address - Street 1:10724 155TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-1924
Practice Address - Country:US
Practice Address - Phone:347-510-9972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303041164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse