Provider Demographics
NPI:1619481686
Name:HOWARD, PEGGY
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:HOWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:LEA
Other - Last Name:FULMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2020 BUCKLEY TRL
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3484
Mailing Address - Country:US
Mailing Address - Phone:404-384-1108
Mailing Address - Fax:
Practice Address - Street 1:2020 BUCKLEY TRL
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3484
Practice Address - Country:US
Practice Address - Phone:404-384-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2018-12-11
Deactivation Date:2018-10-02
Deactivation Code:
Reactivation Date:2018-12-05
Provider Licenses
StateLicense IDTaxonomies
GARN188890163WC0200X, 363LG0600X, 363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care