Healthcare Provider Details

I. General information

NPI: 1326395831
Provider Name (Legal Business Name): DIANE PENA MA, MSED, COMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 12/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4830 40TH ST APT. 1G
SUNNYSIDE NY
11104-4146
US

IV. Provider business mailing address

4830 40TH ST APT. 1G
SUNNYSIDE NY
11104-4146
US

V. Phone/Fax

Practice location:
  • Phone: 917-698-3771
  • Fax:
Mailing address:
  • Phone: 917-698-3771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number616526051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: