Provider Demographics
NPI: | 1306382726 |
---|---|
Name: | WHEATLEY, MARYKATHRINE (NP) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARYKATHRINE |
Middle Name: | |
Last Name: | WHEATLEY |
Suffix: | |
Gender: | F |
Credentials: | NP |
Other - Prefix: | |
Other - First Name: | MARYKATHRINE |
Other - Middle Name: | |
Other - Last Name: | LEY |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 1300 ETHAN WAY STE 600 |
Mailing Address - Street 2: | |
Mailing Address - City: | SACRAMENTO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95825-2296 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 5 MEDICAL PLAZA DR STE 190 |
Practice Address - Street 2: | |
Practice Address - City: | ROSEVILLE |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95661-2867 |
Practice Address - Country: | US |
Practice Address - Phone: | 916-679-3590 |
Practice Address - Fax: | 916-482-3647 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2017-01-09 |
Last Update Date: | 2023-03-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 811923 | 163W00000X |
CA | 95006393 | 363L00000X, 363LA2100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No | 163W00000X | Nursing Service Providers | Registered Nurse | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |