Healthcare Provider Details

I. General information

NPI: 1174554430
Provider Name (Legal Business Name): KIMBERLY R PECKHAM FNP, NPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2646 W STATE ST
OLEAN NY
14760-1866
US

IV. Provider business mailing address

2646 W STATE ST
OLEAN NY
14760-1866
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-9344
  • Fax: 716-372-9497
Mailing address:
  • Phone: 716-372-9344
  • Fax: 716-372-9497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number400892
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number332683
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: