Healthcare Provider Details

I. General information

NPI: 1457754392
Provider Name (Legal Business Name): JOSE PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15641 SW 8TH LN
MIAMI FL
33194-2409
US

IV. Provider business mailing address

15641 SW 8TH LN
MIAMI FL
33194-2409
US

V. Phone/Fax

Practice location:
  • Phone: 786-487-6204
  • Fax:
Mailing address:
  • Phone: 786-487-6204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9255431
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9255431
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: