Provider Demographics
NPI:1093028805
Name:FERTIG, ATHENA C (APRN,PMHNP-BC,NP-C)
Entity Type:Individual
Prefix:MRS
First Name:ATHENA
Middle Name:C
Last Name:FERTIG
Suffix:
Gender:F
Credentials:APRN,PMHNP-BC,NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W BROADWAY STE 240
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9028
Mailing Address - Country:US
Mailing Address - Phone:712-266-3577
Mailing Address - Fax:712-336-8541
Practice Address - Street 1:300 W BROADWAY STE 240
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-9028
Practice Address - Country:US
Practice Address - Phone:712-266-3577
Practice Address - Fax:712-336-8541
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111149363L00000X, 363LF0000X, 363LP2300X
IAA149479363LF0000X, 363L00000X
IAG171495363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE48515OtherBCBS NE (PLH)
NE47279OtherBCBS NE
NE10025024400Medicaid
NE10025024300Medicaid
NE099471016Medicare UPIN
NENA1691004Medicare PIN
NE48515OtherBCBS NE (PLH)