Provider Demographics
NPI:1982114138
Name:CHEATHAM, PEGGY RUTH
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:RUTH
Last Name:CHEATHAM
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 1:317 S DAY ST
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2913
Mailing Address - Country:US
Mailing Address - Phone:307-272-6805
Mailing Address - Fax:
Practice Address - Street 1:317 S DAY ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435
Practice Address - Country:US
Practice Address - Phone:307-272-6805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY0142464500Medicaid