Provider Demographics
NPI:1013001247
Name:JEROME, PEGGY ANNE (APRN)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANNE
Last Name:JEROME
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 E CLIFF SIDE CT
Mailing Address - Street 2:209
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-0798
Mailing Address - Country:US
Mailing Address - Phone:801-563-0708
Mailing Address - Fax:801-566-5939
Practice Address - Street 1:8537 REDWOOD RD
Practice Address - Street 2:SUITE A - MAIN LEVEL
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9311
Practice Address - Country:US
Practice Address - Phone:801-568-2898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT278825-4405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health