Provider Demographics
NPI:1861932162
Name:PEGUES, GLORIA J
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:PEGUES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:J
Other - Last Name:SHIPP/TISDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:7117 MILLERS GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-4179
Mailing Address - Country:US
Mailing Address - Phone:901-831-2423
Mailing Address - Fax:
Practice Address - Street 1:7117 MILLERS GLEN WAY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-4179
Practice Address - Country:US
Practice Address - Phone:901-831-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP316596164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse