Healthcare Provider Details

I. General information

NPI: 1750100442
Provider Name (Legal Business Name): HENRY JUNIOR PENA DNP, AGNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 DIVISION AVE S
GRAND RAPIDS MI
49507-3029
US

IV. Provider business mailing address

3330 HILLCROFT AVE SW
GRAND RAPIDS MI
49548-2148
US

V. Phone/Fax

Practice location:
  • Phone: 616-475-8446
  • Fax:
Mailing address:
  • Phone: 616-856-1992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAG07240076
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG07240076
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704238185
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: