Healthcare Provider Details

I. General information

NPI: 1104745264
Provider Name (Legal Business Name): LISA DE LA PENA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2414 S FAIRVIEW ST
SANTA ANA CA
92704-5318
US

IV. Provider business mailing address

2524 ELDEN AVE APT M
COSTA MESA CA
92627-1371
US

V. Phone/Fax

Practice location:
  • Phone: 714-641-0121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95040334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: