Healthcare Provider Details

I. General information

NPI: 1790613230
Provider Name (Legal Business Name): KRYSTLE TASHANTY C PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 PENINSULA AVE
SAN MATEO CA
94401-1653
US

IV. Provider business mailing address

340 LAKE MERCED BLVD APT 5
DALY CITY CA
94015-3121
US

V. Phone/Fax

Practice location:
  • Phone: 650-286-4396
  • Fax:
Mailing address:
  • Phone: 650-457-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBCBA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: