Provider Demographics
NPI:1780909036
Name:PEACOCK, SANDRA M (APRN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-4964
Mailing Address - Country:US
Mailing Address - Phone:337-528-7992
Mailing Address - Fax:337-528-7994
Practice Address - Street 1:423 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-4964
Practice Address - Country:US
Practice Address - Phone:337-528-7992
Practice Address - Fax:337-528-7994
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP02623364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult