Basic Information
| Provider Information | |||||||||
| NPI: | 1104828276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEAK | ||||||||
| FirstName: | JAYNE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILMORE | ||||||||
| OtherFirstName: | JAYNE | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17015 N. 130TH AVE | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092693162 | ||||||||
| FaxNumber: | 5634213129 | ||||||||
| Practice Location | |||||||||
| Address1: | 9900 BREN ROAD EAST | ||||||||
| Address2: | MAIL ROUTE MN 008-B213 | ||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005610861 | ||||||||
| FaxNumber: | 5634213129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP7967 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 15939 | 01 | IA | IOWA MIDLANDS CHOICE | OTHER | 03262 | 01 | IA | WELLMARK BCBS | OTHER | 1583450 | 05 | IA | MEDICAID | 2583450 | 05 | IA | MEDICAID |