Provider Demographics
NPI:1255224424
Name:PEACH, KATIE I (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:I
Last Name:PEACH
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 RUBY ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2565
Mailing Address - Country:US
Mailing Address - Phone:315-338-5360
Mailing Address - Fax:315-334-7528
Practice Address - Street 1:1001 RUBY ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2565
Practice Address - Country:US
Practice Address - Phone:315-338-5360
Practice Address - Fax:315-334-7528
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2375322163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool