Provider Demographics
NPI:1689756934
Name:PETA, NANCY (APRN)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:PETA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 STORRS RD
Mailing Address - Street 2:NATCHAUG HOSPITAL
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1683
Mailing Address - Country:US
Mailing Address - Phone:860-456-1311
Mailing Address - Fax:860-450-0165
Practice Address - Street 1:189 STORRS RD
Practice Address - Street 2:NATCHAUG HOSPITAL
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1683
Practice Address - Country:US
Practice Address - Phone:860-456-1311
Practice Address - Fax:860-450-0165
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001985363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S86242Medicare UPIN