Provider Demographics
NPI:1487295713
Name:DALE, MARY ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:DALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:PEEPLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8419 S 73RD PLZ
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046
Mailing Address - Country:US
Mailing Address - Phone:402-991-9060
Mailing Address - Fax:402-991-9052
Practice Address - Street 1:8419 S 73RD PLZ
Practice Address - Street 2:SUITE 101
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046
Practice Address - Country:US
Practice Address - Phone:402-991-9060
Practice Address - Fax:402-991-9052
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2398363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant