Provider Demographics
NPI:1942347919
Name:PEACOCK, KIMBERLY L (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
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:PO BOX 8846
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27419-0846
Mailing Address - Country:US
Mailing Address - Phone:336-553-1659
Mailing Address - Fax:336-553-3994
Practice Address - Street 1:4280 N VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6814
Practice Address - Country:US
Practice Address - Phone:229-671-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN193082367500000X
MO127617367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO175118OtherMO BLUE SHIELD
MO915080105Medicaid
AR98727OtherARK BLUE SHIELD
AR141532701Medicaid
GA233419908BMedicaid
GA233419908AMedicaid
GA233419908CMedicaid
MO175118OtherMO BLUE SHIELD
GA233419908AMedicaid
MO915080105Medicaid