Healthcare Provider Details

I. General information

NPI: 1104597947
Provider Name (Legal Business Name): ASHLEY ELIZABETH PEDEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 I 55 FRONTAGE RD N
JACKSON MS
39211-5469
US

IV. Provider business mailing address

101 EAGLE CV
MADISON MS
39110-6629
US

V. Phone/Fax

Practice location:
  • Phone: 601-487-9199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904743
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: