Provider Demographics
NPI:1790093995
Name:MCMILLAN, PEGGY K (RN)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:K
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:FT. LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473
Mailing Address - Country:US
Mailing Address - Phone:573-596-1677
Mailing Address - Fax:573-596-5389
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FT. LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473
Practice Address - Country:US
Practice Address - Phone:573-596-1677
Practice Address - Fax:573-596-5389
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005011794163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management