Healthcare Provider Details

I. General information

NPI: 1467453977
Provider Name (Legal Business Name): PEGGY BRASSELL JUDD LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 RIVER RD KCHU/FP
DOVER DE
19901-3753
US

IV. Provider business mailing address

139 PINE CONE DR
DOVER DE
19901-1965
US

V. Phone/Fax

Practice location:
  • Phone: 302-739-4728
  • Fax: 302-739-7735
Mailing address:
  • Phone: 302-739-4728
  • Fax: 302-739-7735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL2-0004326
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: