1104813179 NPI number — DR. SUSAN D PECK RN, PHD, GNP-BC

Table of content: DR. SUSAN D PECK RN, PHD, GNP-BC (NPI 1104813179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104813179 NPI number — DR. SUSAN D PECK RN, PHD, GNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PECK
Provider First Name:
SUSAN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
RN, PHD, GNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104813179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1417 WILSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701-4808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-829-7325
Provider Business Mailing Address Fax Number:
715-895-8573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2130 BRACKETT AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701-4928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-895-8571
Provider Business Practice Location Address Fax Number:
715-895-8573
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  325-033 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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