Provider Demographics
NPI:1700041654
Name:PRUCHNICKI, PEGGY ANN (NP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:PRUCHNICKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5568 S FORT APACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-3602
Mailing Address - Country:US
Mailing Address - Phone:702-274-6559
Mailing Address - Fax:
Practice Address - Street 1:11441 ALLERTON PARK DR UNIT 402
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-3376
Practice Address - Country:US
Practice Address - Phone:702-279-6683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5774479-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBK072ZMedicare PIN