Healthcare Provider Details

I. General information

NPI: 1700836699
Provider Name (Legal Business Name): TERI S. PEAK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 N SAINT JOSEPH AVE 101
NILES MI
49120-2203
US

IV. Provider business mailing address

42 N SAINT JOSEPH AVE 101
NILES MI
49120-2203
US

V. Phone/Fax

Practice location:
  • Phone: 269-684-6697
  • Fax: 269-684-5286
Mailing address:
  • Phone: 269-684-6697
  • Fax: 269-684-5286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71002118A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704246990
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: