Provider Demographics
NPI:1215094214
Name:PETSCH, RITA (ARNP)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:PETSCH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642117
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-8117
Mailing Address - Country:US
Mailing Address - Phone:402-717-4377
Mailing Address - Fax:
Practice Address - Street 1:809 ELM ST
Practice Address - Street 2:
Practice Address - City:MISSOURI VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51555-1140
Practice Address - Country:US
Practice Address - Phone:712-642-2794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101382363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P07019Medicare UPIN
05528Medicare ID - Type Unspecified