Healthcare Provider Details

I. General information

NPI: 1508774837
Provider Name (Legal Business Name): NICOLE PENA MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 S 6TH AVE
TUCSON AZ
85723-0001
US

IV. Provider business mailing address

6620 S PORTUGAL AVE
TUCSON AZ
85757-8508
US

V. Phone/Fax

Practice location:
  • Phone: 520-792-1450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86474805
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: