Basic Information
| Provider Information | |||||||||
| NPI: | 1609153741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTA | ||||||||
| FirstName: | MARY KATHRYN | ||||||||
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| Credential: | APRN-CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 W NORFOLK AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687014438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023714880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 W NORFOLK AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687014438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023714880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2011 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 114001 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 163W00000X | 27389 | NE | N | Nursing Service Providers | Registered Nurse |
No ID Information.