Provider Demographics
NPI:1619904307
Name:MCCONNELL, PEGGY M (GNP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:M
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4078
Mailing Address - Fax:423-439-4060
Practice Address - Street 1:207 E MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4633
Practice Address - Country:US
Practice Address - Phone:423-926-2500
Practice Address - Fax:423-926-5999
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN005102363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100049918OtherPHP
TN4102133OtherBLUECROSSBLUESHIELD
TNTN01E4OtherJOHN DEERE
TN3903661Medicaid
TN3903661Medicaid
TNPO8313Medicare UPIN