Healthcare Provider Details

I. General information

NPI: 1871520825
Provider Name (Legal Business Name): PEGGY A PRESNELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W MAIN ST
FREDERICKTOWN MO
63645-1111
US

IV. Provider business mailing address

611 W MAIN ST
FREDERICKTOWN MO
63645-1111
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-3341
  • Fax: 573-783-1096
Mailing address:
  • Phone: 573-783-3341
  • Fax: 573-783-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2000172540
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: