Healthcare Provider Details

I. General information

NPI: 1003699505
Provider Name (Legal Business Name): CASSIE PEACOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 INDIAN HILLS DR
PACE FL
32571-8728
US

IV. Provider business mailing address

3316 INDIAN HILLS DR
PACE FL
32571-8728
US

V. Phone/Fax

Practice location:
  • Phone: 850-261-4917
  • Fax:
Mailing address:
  • Phone: 850-261-4917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11026951
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11026951
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: