Maritta A Penegor, NP-BC

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

70000040A Issued in IN

Practice address

24 Joliet St
Suite 401
Dyer, IN 46311-1705

Phone

(219) 865-0893

Fax

(219) 865-3599

NPI assigned

Aug 31, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156982400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1190851200000",
    "number": "1205947983",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3615 PARK DR",
            "address_2": "SUITE 203",
            "city": "OLYMPIA FIELDS",
            "state": "IL",
            "postal_code": "604611186",
            "telephone_number": "708-748-9800",
            "fax_number": "708-748-9807"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24 JOLIET ST",
            "address_2": "SUITE 401",
            "city": "DYER",
            "state": "IN",
            "postal_code": "463111705",
            "telephone_number": "219-865-0893",
            "fax_number": "219-865-3599"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PENEGOR",
        "first_name": "MARITTA",
        "middle_name": "A",
        "credential": "NP-BC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-08-31",
        "last_updated": "2007-09-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "IN",
            "license": "70000040A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P00150268",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Nurse Practitioner in Dyer, IN
• Providers in Dyer, IN by specialty
• Nurse Practitioner in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.