Provider Demographics
NPI:1194106005
Name:PEACOCK, PAULA (ARNP)
Entity type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:520 A1A N STE 101
Practice Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2260
Practice Address - Country:US
Practice Address - Phone:904-273-6900
Practice Address - Fax:904-273-9022
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9262800363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIN PROCESSOtherRAILROAD MEDICARE
FLIN PROCESSOtherRAILROAD MEDICARE