Healthcare Provider Details

I. General information

NPI: 1700796620
Provider Name (Legal Business Name): BREANNA PENA
Entity Type: Individual
Gender:
Sole Proprietor: Y

Provider Other Name: RIVER PENA

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5511 CENTRAL AVE NW
ALBUQUERQUE NM
87105-1890
US

IV. Provider business mailing address

9309 MARRON CIR NE APT B
ALBUQUERQUE NM
87112-5129
US

V. Phone/Fax

Practice location:
  • Phone: 505-206-0288
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: