1982094298 NPI number — MRS. DEIDRE CELESTE PEACOCK NP

Table of content: MRS. DEIDRE CELESTE PEACOCK NP (NPI 1982094298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982094298 NPI number — MRS. DEIDRE CELESTE PEACOCK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEACOCK
Provider First Name:
DEIDRE
Provider Middle Name:
CELESTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DORMAN
Provider Other First Name:
DEIDRE
Provider Other Middle Name:
CELESTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982094298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 KENT RD STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-1697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-388-9393
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 KENT RD STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-1697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-388-9393
Provider Business Practice Location Address Fax Number:
229-388-9855
Provider Enumeration Date:
01/26/2015

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: 363L00000X , with the licence number:  RN176798 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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