Provider Demographics
NPI:1841720513
Name:PELC, MIRI ANN
Entity type:Individual
Prefix:
First Name:MIRI
Middle Name:ANN
Last Name:PELC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 W 49TH STREET PL
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2382
Mailing Address - Country:US
Mailing Address - Phone:308-224-5574
Mailing Address - Fax:
Practice Address - Street 1:300 N COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434-2228
Practice Address - Country:US
Practice Address - Phone:402-643-2971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant