Doctor Name: | PEGGY ICKES |
NPI Number: | 1255681474 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | FNP-BC |
License Number: | CNP-02030 |
Business Practice Address: | 1445 35th St Los Alamos, NM - 875442107 |
Business Phone Number: | 5056600317 |
Business Fax Number: | |
Mailing Address: | 1445 35th St, LOS ALAMOS |
State: | NM |
Postal Code: | 875442107 |
Phone Number: | 5056600317 |
Fax Number: | |
NPI Enumeration Date: | 09/14/2012 |
NPI Last Update Date: | 09/14/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | CNP-02030 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NM |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |