Provider Demographics
NPI:1255428793
Name:FOGG, PEGGY (CRNP)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:
Last Name:FOGG
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 PETER BRYCE BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-7456
Mailing Address - Country:US
Mailing Address - Phone:205-348-6262
Mailing Address - Fax:205-348-4121
Practice Address - Street 1:48 MEDICAL PARK DR E STE 355
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3470
Practice Address - Country:US
Practice Address - Phone:205-838-3036
Practice Address - Fax:205-838-5832
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041333443363L00000X
IL209004753363L00000X
AL0371998363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-166208OtherBLUE CROSS