Provider Demographics
NPI:1063548428
Name:PETERSON, MARY K (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:PETERSON
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 1:451 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3070
Mailing Address - Country:US
Mailing Address - Phone:203-248-8888
Mailing Address - Fax:860-621-5169
Practice Address - Street 1:451 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3070
Practice Address - Country:US
Practice Address - Phone:203-248-8888
Practice Address - Fax:860-621-5169
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000666363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000666OtherSTATE OF CT LICENSE #