Provider Demographics
NPI:1477000610
Name:PENSERO, MARY A (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:PENSERO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MEANEY CIRCLE EXT
Mailing Address - Street 2:12 M
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6180
Mailing Address - Country:US
Mailing Address - Phone:315-342-3410
Mailing Address - Fax:
Practice Address - Street 1:12 MEANEY CIRCLE EXT
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-6180
Practice Address - Country:US
Practice Address - Phone:315-342-3410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY477587-1251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)