Provider Demographics
NPI:1811394828
Name:PEACOCK, ALICIA NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:NICOLE
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2956
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-918-4601
Mailing Address - Fax:
Practice Address - Street 1:1850 EAST HWY 66
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-918-4602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02574363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care