Provider Demographics
NPI:1972018158
Name:PEGG, EMILY
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:
Last Name:PEGG
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 1:20315 SUTTER CREEK DR APT 123
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3960
Mailing Address - Country:US
Mailing Address - Phone:920-915-9572
Mailing Address - Fax:
Practice Address - Street 1:20315 SUTTER CREEK DR APT 123
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-3960
Practice Address - Country:US
Practice Address - Phone:920-915-9572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-09
Last Update Date:2017-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN817425164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse