Provider Demographics
NPI:1316958127
Name:PEASLEY, SANDRA DEE (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:DEE
Last Name:PEASLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:401-273-2919
Practice Address - Street 1:1405 S COUNTY TRL STE 510
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-5097
Practice Address - Country:US
Practice Address - Phone:401-736-4570
Practice Address - Fax:401-921-6931
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22463363LF0000X
RIAPRN02152363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1316958127Medicaid
MT1316958127Medicaid
WAS95986Medicare UPIN
WA8806645Medicare ID - Type Unspecified
MT1316958127Medicaid
MTM011004044Medicare PIN