Provider Demographics
NPI:1871155119
Name:PECK, KATHLEEN LYN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:LYN
Last Name:PECK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:LYN
Other - Last Name:DETESO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:13 BITTERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:STRATHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03885-2565
Mailing Address - Country:US
Mailing Address - Phone:603-957-1863
Mailing Address - Fax:
Practice Address - Street 1:333 BORTHWICK AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7128
Practice Address - Country:US
Practice Address - Phone:603-433-4045
Practice Address - Fax:603-559-4123
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH059649-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered