Provider Demographics
NPI:1134464738
Name:MAYO, PENNY TALCOTT (RN, CDCES)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:TALCOTT
Last Name:MAYO
Suffix:
Gender:F
Credentials:RN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-793-9715
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:1550 S PIONEER WAY
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4613
Practice Address - Country:US
Practice Address - Phone:509-793-9780
Practice Address - Fax:509-764-3246
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00165575163WD0400X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2040700Medicaid