Provider Demographics
NPI:1760078018
Name:SMITH, PEGGY ROSE
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6911 38TH PL NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-7554
Mailing Address - Country:US
Mailing Address - Phone:425-268-8017
Mailing Address - Fax:
Practice Address - Street 1:6911 38TH PL NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-7554
Practice Address - Country:US
Practice Address - Phone:425-268-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9023-53174400000X
CA6399-46374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174400000XOther Service ProvidersSpecialist