Healthcare Provider Details

I. General information

NPI: 1154829463
Provider Name (Legal Business Name): ALEJANDRA LUCIA PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 WAPLES MILL RD STE 100
FAIRFAX VA
22030-7475
US

IV. Provider business mailing address

2963 MOCKERNUT CT
HERNDON VA
20171-2331
US

V. Phone/Fax

Practice location:
  • Phone: 703-237-2219
  • Fax: 703-237-2729
Mailing address:
  • Phone: 703-463-8696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133002298
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: