Healthcare Provider Details

I. General information

NPI: 1205270451
Provider Name (Legal Business Name): PATRICIA LIDA PENA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 EMERALD RD
GREENWOOD SC
29646-8833
US

IV. Provider business mailing address

356 HANOVER RD
ABBEVILLE SC
29620-5262
US

V. Phone/Fax

Practice location:
  • Phone: 864-941-5540
  • Fax: 864-388-7887
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number61037
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: