Healthcare Provider Details

I. General information

NPI: 1255428793
Provider Name (Legal Business Name): PEGGY FOGG CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MEDICAL PARK DR E STE 355
BIRMINGHAM AL
35235-3470
US

IV. Provider business mailing address

750 PETER BRYCE BLVD
TUSCALOOSA AL
35401-7456
US

V. Phone/Fax

Practice location:
  • Phone: 205-838-3036
  • Fax: 205-838-5832
Mailing address:
  • Phone: 205-348-6262
  • Fax: 205-348-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number041333443
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209004753
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0371998
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: