Healthcare Provider Details

I. General information

NPI: 1407640600
Provider Name (Legal Business Name): NICOLLE MARIE MARTE PENA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2025
Last Update Date: 08/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVENUE PEDIATRIC RESIDENCY TRAINING PROGRAM
MIAMI FL
33136
US

IV. Provider business mailing address

1611 NW 12TH AVENUE PEDIATRIC RESIDENCY TRAINING PROGRAM
MIAMI FL
33136
US

V. Phone/Fax

Practice location:
  • Phone: 305-355-1122
  • Fax:
Mailing address:
  • Phone: 305-355-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: