Provider Demographics
NPI:1871021600
Name:PEACOCK, KIMBERLY H
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:H
Last Name:PEACOCK
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 1:20 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:CATAULA
Mailing Address - State:GA
Mailing Address - Zip Code:31804-2645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:CATAULA
Practice Address - State:GA
Practice Address - Zip Code:31804-2645
Practice Address - Country:US
Practice Address - Phone:202-744-3445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230391363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily