Healthcare Provider Details

I. General information

NPI: 1104828276
Provider Name (Legal Business Name): JAYNE ELLEN PEAK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAYNE ELLEN GILMORE ARNP

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 BREN ROAD EAST MAIL ROUTE MN 008-B213
MINNETONKA MN
55343
US

IV. Provider business mailing address

17015 N. 130TH AVE
SUN CITY WEST AZ
85375
US

V. Phone/Fax

Practice location:
  • Phone: 800-561-0861
  • Fax: 563-421-3129
Mailing address:
  • Phone: 309-269-3162
  • Fax: 563-421-3129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP7967
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: