Provider Demographics
NPI:1295938645
Name:PETGES, MARYKAY (RN)
Entity type:Individual
Prefix:MRS
First Name:MARYKAY
Middle Name:
Last Name:PETGES
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 1:101 BIRCH DR SW
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065-8962
Mailing Address - Country:US
Mailing Address - Phone:815-765-1418
Mailing Address - Fax:815-765-0971
Practice Address - Street 1:101 BIRCH DR SW
Practice Address - Street 2:
Practice Address - City:POPLAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:61065-8962
Practice Address - Country:US
Practice Address - Phone:815-765-1418
Practice Address - Fax:815-765-0971
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics