Healthcare Provider Details

I. General information

NPI: 1780909036
Provider Name (Legal Business Name): SANDRA M PEACOCK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2010
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 CYPRESS ST
SULPHUR LA
70663-4964
US

IV. Provider business mailing address

423 CYPRESS ST
SULPHUR LA
70663-4964
US

V. Phone/Fax

Practice location:
  • Phone: 337-528-7992
  • Fax: 337-528-7994
Mailing address:
  • Phone: 337-528-7992
  • Fax: 337-528-7994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAP02623
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: