Provider Demographics
NPI:1558646760
Name:PEEBLES, JONISTA M
Entity Type:Individual
Prefix:MS
First Name:JONISTA
Middle Name:M
Last Name:PEEBLES
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 1:4898 LINVINGSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-0026
Mailing Address - Country:US
Mailing Address - Phone:937-469-7520
Mailing Address - Fax:
Practice Address - Street 1:4898 LIVINGSTONE AVE
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-1490
Practice Address - Country:US
Practice Address - Phone:937-469-7520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH23550895207K00000X, 207P00000X, 207Q00000X, 207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice