Provider Demographics
NPI:1841247244
Name:BRAZELL, PEGGY LOREE (NP)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:LOREE
Last Name:BRAZELL
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:
Practice Address - Street 1:255 ENTERPRISE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6300
Practice Address - Country:US
Practice Address - Phone:864-454-8120
Practice Address - Fax:864-454-8125
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3023363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1046Medicaid
SCP671367951Medicare PIN
SCNP1046Medicaid
SCP671368157Medicare PIN