Provider Demographics
NPI:1962170365
Name:WELCH, PEGGY SUZANNE
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUZANNE
Last Name:WELCH
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 1:1829 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7816
Mailing Address - Country:US
Mailing Address - Phone:847-269-7003
Mailing Address - Fax:
Practice Address - Street 1:4 N DEER POINT RD STE 1008
Practice Address - Street 2:
Practice Address - City:HAINESVILLE
Practice Address - State:IL
Practice Address - Zip Code:60030-3814
Practice Address - Country:US
Practice Address - Phone:847-543-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002293363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health