Healthcare Provider Details

I. General information

NPI: 1649832288
Provider Name (Legal Business Name): TINA M MAYO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W 15TH ST
EDMOND OK
73013-3621
US

IV. Provider business mailing address

1609 HANNA DR
DEL CITY OK
73115-3111
US

V. Phone/Fax

Practice location:
  • Phone: 405-702-3679
  • Fax:
Mailing address:
  • Phone: 405-702-3679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: