Provider Demographics
NPI:1700072873
Name:PEACOCK, DIANE HELEN (RN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:HELEN
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 S DANEHURST AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4855
Mailing Address - Country:US
Mailing Address - Phone:626-963-9214
Mailing Address - Fax:
Practice Address - Street 1:1019 S DANEHURST AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4855
Practice Address - Country:US
Practice Address - Phone:626-963-9214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403521163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse