Provider Demographics
NPI:1982094298
Name:PEACOCK, DEIDRE CELESTE (NP)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:CELESTE
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DEIDRE
Other - Middle Name:CELESTE
Other - Last Name:DORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:39 KENT RD STE 2
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1697
Mailing Address - Country:US
Mailing Address - Phone:229-388-9393
Mailing Address - Fax:
Practice Address - Street 1:39 KENT RD STE 2
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1697
Practice Address - Country:US
Practice Address - Phone:229-388-9393
Practice Address - Fax:229-388-9855
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176798363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner