=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720086119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEGGY ANN EVERT RN, CNS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W WALLACE ST SUITE A-1
-----------------------------------------------------
City | FINDLAY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45840-1242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-423-2996
-----------------------------------------------------
Fax | 419-423-1379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16472 TOWNSHIP ROAD 207
-----------------------------------------------------
City | FINDLAY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45840-9420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-423-2996
-----------------------------------------------------
Fax | 419-423-1379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | RN-132398
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------