Basic Information
| Provider Information | |||||||||
| NPI: | 1942347919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEACOCK | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8846 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274190846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Practice Location | |||||||||
| Address1: | 4280 N VALDOSTA RD | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316026814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2296712066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 127617 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN193082 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 175118 | 01 | MO | MO BLUE SHIELD | OTHER | 233419908C | 05 | GA | MEDICAID | 233419908A | 05 | GA | MEDICAID | 233419908B | 05 | GA | MEDICAID | 141532701 | 05 | AR | MEDICAID | 98727 | 01 | AR | ARK BLUE SHIELD | OTHER | 915080105 | 05 | MO | MEDICAID |