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
StateLicense IDTaxonomies
CA811923163W00000X
CA95006393363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner