Healthcare Provider Details

I. General information

NPI: 1942611983
Provider Name (Legal Business Name): FIORDALIZA PENA-SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12401 E 43RD ST S STE 121
INDEPENDENCE MO
64055-5925
US

IV. Provider business mailing address

325 E PARTRIDGE AVE
INDEPENDENCE MO
64055-1452
US

V. Phone/Fax

Practice location:
  • Phone: 816-908-1469
  • Fax:
Mailing address:
  • Phone: 816-908-1469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4900
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2018037728
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: