Provider Demographics
NPI:1609153741
Name:PETTA, MARY KATHRYN (APRN-CNS)
Entity Type:Individual
Prefix:
First Name:MARY KATHRYN
Middle Name:
Last Name:PETTA
Suffix:
Gender:F
Credentials:APRN-CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 W NORFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-4438
Mailing Address - Country:US
Mailing Address - Phone:402-371-4880
Mailing Address - Fax:
Practice Address - Street 1:2700 W NORFOLK AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4438
Practice Address - Country:US
Practice Address - Phone:402-371-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE114001364S00000X
NE27389163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163W00000XNursing Service ProvidersRegistered Nurse