Provider Demographics
NPI:1861454126
Name:PEACOCK-PRESTON, KERRIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KERRIE
Middle Name:
Last Name:PEACOCK-PRESTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2762
Mailing Address - Country:US
Mailing Address - Phone:904-253-1220
Mailing Address - Fax:
Practice Address - Street 1:3225 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2762
Practice Address - Country:US
Practice Address - Phone:904-253-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0020409-00Medicaid
FL0020409-00Medicaid