Provider Demographics
NPI:1588948996
Name:WOLPERT, PEGGY ANN (CNP)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:ANN
Last Name:WOLPERT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 E MAIN ST # 11C
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5100
Mailing Address - Country:US
Mailing Address - Phone:217-554-3000
Mailing Address - Fax:
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-554-5383
Practice Address - Fax:217-554-4807
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008961207Q00000X
IN71007712A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300010497Medicaid
IN71007712AOtherINDIANA LICENSE