Provider Demographics
NPI:1023429172
Name:HEATHERLY, PEGGY LUCILLE (LMT)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:LUCILLE
Last Name:HEATHERLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1133
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37605-1133
Mailing Address - Country:US
Mailing Address - Phone:423-943-1600
Mailing Address - Fax:
Practice Address - Street 1:708 E UNAKA AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4128
Practice Address - Country:US
Practice Address - Phone:423-943-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000004981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist