Provider Demographics
NPI:1871204099
Name:PEGUERO, EVELYN D
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:D
Last Name:PEGUERO
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 1:521 STATE ROUTE 32
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:10930-5133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:521 STATE ROUTE 32
Practice Address - Street 2:
Practice Address - City:HIGHLAND MILLS
Practice Address - State:NY
Practice Address - Zip Code:10930-5133
Practice Address - Country:US
Practice Address - Phone:917-348-9453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306587164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse