Healthcare Provider Details

I. General information

NPI: 1114700499
Provider Name (Legal Business Name): DENISE LASHAY PEACOCK LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 HOLLAND RD STE F
MAUMEE OH
43537-1656
US

IV. Provider business mailing address

4600 MONTGOMERY RD
CINCINNATI OH
45212-2697
US

V. Phone/Fax

Practice location:
  • Phone: 866-934-7450
  • Fax:
Mailing address:
  • Phone: 833-510-4357
  • Fax: 866-460-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.176108.MEDS-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: