Provider Demographics
NPI:1790318046
Name:BAILEY, PEGGY SUE
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5212 CORTLAND AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-7254
Mailing Address - Country:US
Mailing Address - Phone:440-812-7831
Mailing Address - Fax:
Practice Address - Street 1:5131 WARNER RD
Practice Address - Street 2:
Practice Address - City:KINSMAN
Practice Address - State:OH
Practice Address - Zip Code:44428-9747
Practice Address - Country:US
Practice Address - Phone:330-442-5849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401499770313374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide