Provider Demographics
NPI:1013492487
Name:PEACOCK, HEATHER (RN, BSN, RNC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:RN, BSN, RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 NW CIRCLE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:996 NW CIRCLE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1485
Practice Address - Country:US
Practice Address - Phone:541-768-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201390459RN163WS0121X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0121XNursing Service ProvidersRegistered NursePlastic Surgery