Provider Demographics
NPI:1912459827
Name:PECKHAM, ELIZABETH NICOLE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:PECKHAM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 BELL ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1724
Mailing Address - Country:US
Mailing Address - Phone:860-942-4108
Mailing Address - Fax:
Practice Address - Street 1:300 STAFFORD ST STE 102
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3581
Practice Address - Country:US
Practice Address - Phone:413-748-7095
Practice Address - Fax:413-733-5604
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9239363LF0000X
MA2279707363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily