Provider Demographics
NPI:1063535391
Name:PECKENPAUGH, NANCY JAMISON (MSED RD CDN CDE)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:JAMISON
Last Name:PECKENPAUGH
Suffix:
Gender:F
Credentials:MSED RD CDN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 TRUMANSBURG ROAD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1314
Mailing Address - Country:US
Mailing Address - Phone:607-272-1297
Mailing Address - Fax:607-272-2366
Practice Address - Street 1:1216 TRUMANSBURG ROAD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1314
Practice Address - Country:US
Practice Address - Phone:607-272-1297
Practice Address - Fax:607-272-2366
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0012301133V00000X
IL09224400163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY204479481OtherBC/BS
NY4410036OtherAETNA
NY000916207001OtherHEALTH NOW INSURANCE CO
NY000916207001OtherHEALTH NOW INSURANCE CO