Provider Demographics
NPI:1942623012
Name:PEAK, HEATHER (RN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PEAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 GWINNETT DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5671
Mailing Address - Country:US
Mailing Address - Phone:770-241-5235
Mailing Address - Fax:678-682-8747
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5671
Practice Address - Country:US
Practice Address - Phone:770-241-5235
Practice Address - Fax:678-682-8747
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN119363163W00000X, 163WA0400X, 163WP0808X, 251J00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAN/AMedicaid
GA123456789Medicare UPIN
GA0000000000Medicare NSC
GAN/AMedicaid