Provider Demographics
NPI:1174255798
Name:PECKHAM, AUDREY LYNN
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LYNN
Last Name:PECKHAM
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 1:105 GARRETTS GRV
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492-3218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 GARRETTS GRV
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492-3218
Practice Address - Country:US
Practice Address - Phone:315-939-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350234363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner