Basic Information
| Provider Information | |||||||||
| NPI: | 1134464738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYO | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | TALCOTT | ||||||||
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| Credential: | RN, CDCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S COOLIDGE ST | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988371872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939715 | ||||||||
| FaxNumber: | 5097643244 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 S PIONEER WAY | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988374613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939780 | ||||||||
| FaxNumber: | 5097643246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2012 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | RN00165575 | WA | Y | Nursing Service Providers | Registered Nurse | Diabetes Educator | 163WS0200X | RN00165575 | WA | N | Nursing Service Providers | Registered Nurse | School |
ID Information
| ID | Type | State | Issuer | Description | 2040700 | 05 | WA | MEDICAID |