MEDICARE: MRS. LISA MARIE PEACOCK R.N.C., W.H.N.P.

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	363LW0102X	Women's Health Nurse Practitioner	4704184255	MI

General Provider Information

NPI Number	:	1952475287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA MARIE PEACOCK R.N.C., W.H.N.P.

Provider Business Mailing Address
First Line	:	5426 BREEZEHILL DR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-6908
Country	:	US
Telephone Number	:	231-947-4956
Fax Number	:

Provider Business Practice Location Address
First Line	:	2325 GARFIELD RD N
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-5127
Country	:	US
Telephone Number	:	231-922-6416
Fax Number	:

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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