Provider Demographics
NPI:1609459577
Name:PEABODY, MARY KATHRYN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:PEABODY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:HIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 628231 MAIL CODE: 5068
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32862-8231
Mailing Address - Country:US
Mailing Address - Phone:678-344-8900
Mailing Address - Fax:
Practice Address - Street 1:10730 MEDLOCK BRIDGE RD
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-2637
Practice Address - Country:US
Practice Address - Phone:404-948-4073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AS0400X
GA10377363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant