Healthcare Provider Details

I. General information

NPI: 1598602682
Provider Name (Legal Business Name): MANDY PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5246 W OVERLAND RD
BOISE ID
83705-2636
US

IV. Provider business mailing address

443 E HEARTHSTONE DR
BOISE ID
83702-1727
US

V. Phone/Fax

Practice location:
  • Phone: 208-407-0574
  • Fax:
Mailing address:
  • Phone: 208-407-0574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: