MEDICARE: MRS. MARY EYONG ETA RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	93728	NE

General Provider Information

NPI Number	:	1417813213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY EYONG ETA RN

Provider Business Mailing Address
First Line	:	12670 FOWLER AVE
Second Line	:	12670 FOWLER AVE
City	:	OMAHA
State	:	NE
Zip	:	68164-1998
Country	:	US
Telephone Number	:	402-301-2311
Fax Number	:

Provider Business Practice Location Address
First Line	:	12670 FOWLER AVE
Second Line	:	12670 FOWLER AVE
City	:	OMAHA
State	:	NE
Zip	:	68164-1998
Country	:	US
Telephone Number	:	402-301-2311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/24/2025
Last Update Date	:	12/24/2025

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