Provider Demographics
NPI:1467748525
Name:PETERSON, MARYBETH F (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARYBETH
Middle Name:F
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7498 OLD BIG CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-9135
Mailing Address - Country:US
Mailing Address - Phone:607-324-4044
Mailing Address - Fax:
Practice Address - Street 1:4600 MILLENNIUM DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454-1197
Practice Address - Country:US
Practice Address - Phone:518-243-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401516-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health