Provider Demographics
NPI:1295892354
Name:PITERA, MARY JO (APRN,BC NP)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:PITERA
Suffix:
Gender:F
Credentials:APRN,BC NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28390 TIMOTHY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-4864
Mailing Address - Country:US
Mailing Address - Phone:586-949-3958
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-4698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704106983363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care