MEDICARE: MRS. FATIMA D PENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	317182-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063822351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. FATIMA D PENA

Provider Business Mailing Address
First Line	:	839 E 19TH ST APT 3B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-3135
Country	:	US
Telephone Number	:	347-613-7272
Fax Number	:

Provider Business Practice Location Address
First Line	:	839 E 19TH ST APT 3B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-3135
Country	:	US
Telephone Number	:	347-613-7272
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2014
Last Update Date	:	05/07/2014

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