Healthcare Provider Details

I. General information

NPI: 1457480071
Provider Name (Legal Business Name): LISA MARIE PECK LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 WILLIS AVE
DAYTONA BEACH FL
32114-2810
US

IV. Provider business mailing address

2710 ROYAL PALM DR
EDGEWATER FL
32141-5319
US

V. Phone/Fax

Practice location:
  • Phone: 386-236-3200
  • Fax:
Mailing address:
  • Phone: 386-427-1252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN5165947
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: