Provider Demographics
NPI:1770129322
Name:MAYO FAMILY HEALTHCARE PLLC
Entity type:Organization
Organization Name:MAYO FAMILY HEALTHCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NP
Authorized Official - Prefix:
Authorized Official - First Name:BILLIESUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-318-1619
Mailing Address - Street 1:5826 E FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-5020
Mailing Address - Country:US
Mailing Address - Phone:208-318-1619
Mailing Address - Fax:208-318-1612
Practice Address - Street 1:5826 E FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5020
Practice Address - Country:US
Practice Address - Phone:208-318-1619
Practice Address - Fax:208-318-1612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-19
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1770129322Medicaid
ID1396245742Medicaid