Provider Demographics
NPI:1942469473
Name:PEACOCK, MAYA SHARIA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:MAYA
Middle Name:SHARIA
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 STILWELL AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-2022
Mailing Address - Country:US
Mailing Address - Phone:419-334-3073
Mailing Address - Fax:
Practice Address - Street 1:915 STILWELL AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2022
Practice Address - Country:US
Practice Address - Phone:419-334-3073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH117804164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse