Healthcare Provider Details

I. General information

NPI: 1659787877
Provider Name (Legal Business Name): PRINCESS DELA PENA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 SAINT DOMINICS DR STE 201
MANTECA CA
95337-7802
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-823-2345
  • Fax: 209-239-1154
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA149269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: