Healthcare Provider Details

I. General information

NPI: 1568967974
Provider Name (Legal Business Name): CELIA ANAIS PENA HEREDIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E RM AB193
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E RM AB193
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-1686
  • Fax:
Mailing address:
  • Phone: 801-585-1686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12377479-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number12377479-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: