Provider Demographics
NPI:1396951190
Name:GILDERSLEEVE, PEGGY (NP)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:GILDERSLEEVE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 FERN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-6025
Mailing Address - Country:US
Mailing Address - Phone:781-821-3210
Mailing Address - Fax:781-821-3216
Practice Address - Street 1:1 DEL POND DR
Practice Address - Street 2:ORCHARD COVE WELLNESS CENTER
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2759
Practice Address - Country:US
Practice Address - Phone:781-821-3210
Practice Address - Fax:781-821-3216
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA145848363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2821OtherBLUE SHIELD
P16942Medicare UPIN
MANP2821Medicare ID - Type Unspecified