Healthcare Provider Details

I. General information

NPI: 1356753933
Provider Name (Legal Business Name): ALYSSA VICTORIA PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 NAPA VALLEY CORPORATE DR BLDG B
NAPA CA
94558-6216
US

IV. Provider business mailing address

1701 MARSHALL RD APT 128
VACAVILLE CA
95687-4505
US

V. Phone/Fax

Practice location:
  • Phone: 707-227-3900
  • Fax:
Mailing address:
  • Phone: 707-392-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95048865
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: