Provider Demographics
NPI:1922046614
Name:PEACOCK, DOROTHY M (CRNA)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:M
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 39TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-2773
Mailing Address - Country:US
Mailing Address - Phone:205-333-2520
Mailing Address - Fax:205-759-6397
Practice Address - Street 1:809 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2029
Practice Address - Country:US
Practice Address - Phone:205-759-7352
Practice Address - Fax:205-759-6397
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-020578163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS43850Medicare UPIN
AL000071727Medicare ID - Type UnspecifiedC.R.N.A.