Healthcare Provider Details

I. General information

NPI: 1710468657
Provider Name (Legal Business Name): ELEANOR GARRETT PEACOCK MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8613 LEE HWY # 200N
FAIRFAX VA
22031-2171
US

IV. Provider business mailing address

625 E MONROE AVE APT 402
ALEXANDRIA VA
22301-3029
US

V. Phone/Fax

Practice location:
  • Phone: 703-208-3155
  • Fax: 703-280-9596
Mailing address:
  • Phone: 703-615-7574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberPGC130
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number0139000425
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: