Provider Demographics
NPI:1770538811
Name:PEPPERSACK, DEO M (NP)
Entity type:Individual
Prefix:
First Name:DEO
Middle Name:M
Last Name:PEPPERSACK
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 1:217 W. GEORGIA AVE. STE 120
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2856
Mailing Address - Country:US
Mailing Address - Phone:208-498-1760
Mailing Address - Fax:208-498-1769
Practice Address - Street 1:217 W GEORGIA AVE STE 120
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6812
Practice Address - Country:US
Practice Address - Phone:208-498-1760
Practice Address - Fax:208-498-1761
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP656A163W00000X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8083269Medicaid
ID806976700Medicaid
IDNP191OtherBLUE CROSS
IDQ26365Medicare UPIN