Active NPI
Patti Jo Peck, NP
- Adult Health Nurse Practitioner
- Grand Rapids, MI
National Provider Identifier
1063473544
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Adult Health Nurse Practitioner
- License
- 4704151401
- Practice address
- 200 Jefferson SE
Grand Rapids, MI 49503 - Phone
- (616) 685-5000
- Fax
- (616) 685-3084
- NPI assigned
- Mar 31, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Neonatal Nurse Practitioner | 363LN0000X | 1494303 | MI | |
| Adult Health Nurse Practitioner | 363LA2200X | 4704151401 | MI | Primary |
Addresses
Primary practice location
200 Jefferson SE
Grand Rapids, MI 49503
Mailing address
245 State St SE
Ste 221
Grand Rapids, MI 49503
Phone (616) 685-1808
Other names 1
- Miss Patti Jo Dykema
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4704151401 | MI | MD | Adult Health Nurse Practitioner |
| 1494303 | MI | MD | Neonatal Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| West Shore Cardiology, PLC | Past | Accepting new patients | |
| Advantage Health Saint Mary'S Medical Group | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
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NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1143763200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1247702400000",
"number": "1063473544",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "245 STATE ST SE",
"address_2": "STE 221",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "49503",
"telephone_number": "616-685-1808",
"fax_number": "616-685-1850"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "200 JEFFERSON SE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "49503",
"telephone_number": "616-685-5000",
"fax_number": "616-685-3084"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PECK",
"first_name": "PATTI",
"middle_name": "JO",
"name_prefix": "Mrs.",
"credential": "NP",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-03-31",
"last_updated": "2009-07-16",
"status": "A"
},
"taxonomies": [
{
"code": "363LN0000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Neonatal",
"state": "MI",
"license": "1494303",
"primary": false
},
{
"code": "363LA2200X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Adult Health",
"state": "MI",
"license": "4704151401",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "PATTI",
"last_name": "DYKEMA",
"middle_name": "JO",
"prefix": "MISS",
"credential": "NNP",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Grand Rapids, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.