Provider Demographics
NPI:1851755680
Name:PEACOCK, SARA LAUREN (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LAUREN
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 CELIA DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-4130
Mailing Address - Country:US
Mailing Address - Phone:601-720-3194
Mailing Address - Fax:
Practice Address - Street 1:411 OAK ST
Practice Address - Street 2:ATTN: CREDENTIALS
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2504
Practice Address - Country:US
Practice Address - Phone:513-984-1800
Practice Address - Fax:513-984-4909
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1063048133V00000X
MSD1651133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered