Basic Information
Provider Information | |||||||||
NPI: | 1841593381 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEEK | ||||||||
FirstName: | THERESA | ||||||||
MiddleName: | KAYE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GARDNER | ||||||||
OtherFirstName: | THERESA | ||||||||
OtherMiddleName: | KAYE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APRN | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1079 | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | KY | ||||||||
PostalCode: | 424191079 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2708270353 | ||||||||
FaxNumber: | 2708274966 | ||||||||
Practice Location | |||||||||
Address1: | 1284 US HIGHWAY 60 W | ||||||||
Address2: |   | ||||||||
City: | MORGANFIELD | ||||||||
State: | KY | ||||||||
PostalCode: | 424376236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2703892323 | ||||||||
FaxNumber: | 2703890526 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2010 | ||||||||
LastUpdateDate: | 03/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1100233 | KY | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 3006685 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 000000745187 | 01 | KY | ANTHEM | OTHER | 7100184940 | 05 | KY |   | MEDICAID |