Provider Demographics
NPI:1760730949
Name:PETERS, MARY A (MSN, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:PETERS
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 BENEDICT AVE STE C
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-2712
Mailing Address - Country:US
Mailing Address - Phone:419-668-0311
Mailing Address - Fax:419-668-0312
Practice Address - Street 1:282 BENEDICT AVE STE C
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2712
Practice Address - Country:US
Practice Address - Phone:419-668-0311
Practice Address - Fax:419-668-0312
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.13596363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070923Medicaid