Healthcare Provider Details

I. General information

NPI: 1366419582
Provider Name (Legal Business Name): PEGGI RYAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PEGGI LUCAS FNP

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W 16TH ST
PUEBLO CO
81003-2728
US

IV. Provider business mailing address

314 W 16TH ST
PUEBLO CO
81003-2728
US

V. Phone/Fax

Practice location:
  • Phone: 719-546-3511
  • Fax: 719-583-1259
Mailing address:
  • Phone: 719-546-3511
  • Fax: 719-583-1259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number1647116
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number107737
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP0000558
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28142.1052
License Number StateWY
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number993030
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: