Provider Demographics
NPI:1366980583
Name:STEWART, PEGGY
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-3013
Mailing Address - Country:US
Mailing Address - Phone:920-265-8631
Mailing Address - Fax:
Practice Address - Street 1:1547 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-3013
Practice Address - Country:US
Practice Address - Phone:920-265-8631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320267164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse