Healthcare Provider Details

I. General information

NPI: 1043345804
Provider Name (Legal Business Name): MRS. PEGGY PALK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 10TH ST TN DEPT OF HEALTH
COOKEVILLE TN
38501-6077
US

IV. Provider business mailing address

3876 OLD GAINESBORO RD
BLOOMINGTON SPRINGS TN
38545-4512
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-7531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number40408
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: