Provider Demographics
NPI:1922058858
Name:DEFOURE, PEGGY A
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:A
Last Name:DEFOURE
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 1:625 EAST 19TH STREET
Mailing Address - Street 2:APT E7
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730
Mailing Address - Country:US
Mailing Address - Phone:479-713-7115
Mailing Address - Fax:479-713-7186
Practice Address - Street 1:600 SOUTH TIMBERLANE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730
Practice Address - Country:US
Practice Address - Phone:870-864-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAO1686363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y648OtherBLUE
AR5Y648OtherBLUE