Provider Demographics
NPI:1992173330
Name:HARRIS, PEGGY L (APRN)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:L
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1595
Mailing Address - Country:US
Mailing Address - Phone:270-691-8070
Mailing Address - Fax:270-691-8026
Practice Address - Street 1:444 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-2846
Practice Address - Country:US
Practice Address - Phone:270-821-4444
Practice Address - Fax:270-821-9188
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1069555163W00000X
KY3009842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100368720Medicaid
KYK196740Medicare PIN