Provider Demographics
NPI:1760532295
Name:PEACOCK, CATHERINE L (RN, APRN)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:L
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:RN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2122
Mailing Address - Country:US
Mailing Address - Phone:602-931-4586
Mailing Address - Fax:602-931-4591
Practice Address - Street 1:9515 W CAMELBACK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-1355
Practice Address - Country:US
Practice Address - Phone:623-772-6999
Practice Address - Fax:623-772-6444
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP180363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S89330Medicare UPIN