Healthcare Provider Details

I. General information

NPI: 1598422073
Provider Name (Legal Business Name): ELIZABETH PELTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4585 FISHING CLUB DR
JACKSON WY
83001-0015
US

IV. Provider business mailing address

PO BOX 7689
JACKSON WY
83002-7689
US

V. Phone/Fax

Practice location:
  • Phone: 808-214-2992
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200224
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: