Provider Demographics
NPI:1992077234
Name:CLEMONS, PEGGY
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:CLEMONS
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 1:173 SINCLAIR RD
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-7941
Mailing Address - Country:US
Mailing Address - Phone:229-423-8593
Mailing Address - Fax:
Practice Address - Street 1:1050 CROWN POINTE PKWY
Practice Address - Street 2:STE 450
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-7707
Practice Address - Country:US
Practice Address - Phone:866-325-5434
Practice Address - Fax:866-325-5340
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN047626364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health