Healthcare Provider Details

I. General information

NPI: 1790093995
Provider Name (Legal Business Name): PEGGY K MCMILLAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 MISSOURI AVE
FT. LEONARD WOOD MO
65473
US

IV. Provider business mailing address

126 MISSOURI AVE
FT. LEONARD WOOD MO
65473
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-1677
  • Fax: 573-596-5389
Mailing address:
  • Phone: 573-596-1677
  • Fax: 573-596-5389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number2005011794
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: