Provider Demographics
NPI:1609356534
Name:PECK, KATHRYN ROSE (CNM)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ROSE
Last Name:PECK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 RIVERVIEW RD
Mailing Address - Street 2:
Mailing Address - City:GAYLORDSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06755-1402
Mailing Address - Country:US
Mailing Address - Phone:914-420-2021
Mailing Address - Fax:
Practice Address - Street 1:94 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6032
Practice Address - Country:US
Practice Address - Phone:203-748-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT491367A00000X
NY001883367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife