Healthcare Provider Details

I. General information

NPI: 1063064426
Provider Name (Legal Business Name): VALERIE PENA POLANCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 7TH ST SE
CEDAR RAPIDS IA
52401-1929
US

IV. Provider business mailing address

543 7TH ST SE
CEDAR RAPIDS IA
52401-1929
US

V. Phone/Fax

Practice location:
  • Phone: 319-861-7895
  • Fax: 319-861-7677
Mailing address:
  • Phone: 319-861-7895
  • Fax: 319-861-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57.248240
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD-51350
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: