Healthcare Provider Details

I. General information

NPI: 1396253357
Provider Name (Legal Business Name): NANCY PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15062 SW 30TH ST
MIAMI FL
33185-4853
US

IV. Provider business mailing address

15062 SW 30TH ST
MIAMI FL
33185-4853
US

V. Phone/Fax

Practice location:
  • Phone: 305-562-2847
  • Fax:
Mailing address:
  • Phone: 305-562-2847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number9253104
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: