Healthcare Provider Details

I. General information

NPI: 1942675970
Provider Name (Legal Business Name): MARY PECKENHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 SIERRA RD
CONCORD CA
94518
US

IV. Provider business mailing address

2000 SIERRA ROAD
CONCORD CA
94518
US

V. Phone/Fax

Practice location:
  • Phone: 925-363-2005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number311218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: