Healthcare Provider Details

I. General information

NPI: 1003268897
Provider Name (Legal Business Name): SANDRA L. PEACH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 NE GLEN OAK AVE
PEORIA IL
61603-3105
US

IV. Provider business mailing address

420 NE GLEN OAK AVE
PEORIA IL
61603-3105
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2343
  • Fax: 309-655-3948
Mailing address:
  • Phone: 309-655-2343
  • Fax: 309-655-3948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014408
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.014408
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: