Healthcare Provider Details

I. General information

NPI: 1619965399
Provider Name (Legal Business Name): PEGGY SMITH ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5861A KAMIAKIN TRL
FAIRCHILD AFB WA
99011-2216
US

IV. Provider business mailing address

5861A KAMIAKIN TRL
FAIRCHILD AIR FORCE BASE WA
99011-2216
US

V. Phone/Fax

Practice location:
  • Phone: 509-247-4564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP30006542
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: