Healthcare Provider Details

I. General information

NPI: 1942590666
Provider Name (Legal Business Name): WENDY MARIE PEACOCK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17145 LENSMAN RD
SAINT ROBERT MO
65584-8612
US

IV. Provider business mailing address

17145 LENSMAN RD
SAINT ROBERT MO
65584-8612
US

V. Phone/Fax

Practice location:
  • Phone: 573-855-5331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number2006021691
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: