MEDICARE: PEGGY ANN PRUCHNICKI NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5774479-4405	UT

General Provider Information

NPI Number	:	1700041654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PEGGY ANN PRUCHNICKI NP

Provider Business Mailing Address
First Line	:	5568 S FORT APACHE RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-3602
Country	:	US
Telephone Number	:	702-274-6559
Fax Number	:

Provider Business Practice Location Address
First Line	:	11441 ALLERTON PARK DR UNIT 402
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89135-3376
Country	:	US
Telephone Number	:	702-279-6683
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	03/02/2023

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