Provider Demographics
NPI:1508664889
Name:JEFFERSON, PENNY M (RN)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:M
Last Name:JEFFERSON
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13829 W WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-3149
Mailing Address - Country:US
Mailing Address - Phone:970-401-0870
Mailing Address - Fax:
Practice Address - Street 1:13829 W WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-3149
Practice Address - Country:US
Practice Address - Phone:970-401-0870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ239909163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator