Provider Demographics
NPI:1912130683
Name:PEACOCK, BRANDY R (NP)
Entity Type:Individual
Prefix:MS
First Name:BRANDY
Middle Name:R
Last Name:PEACOCK
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 1:9107 REDWING CT
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3605
Mailing Address - Country:US
Mailing Address - Phone:318-840-9660
Mailing Address - Fax:
Practice Address - Street 1:200 CORPORATE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3870
Practice Address - Country:US
Practice Address - Phone:800-893-9698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN085735-AP0589363LF0000X
LARN085735-AP05893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily