=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962759878
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LYNN PENA NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2012
-----------------------------------------------------
Last Update Date | 03/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9220 W SUNSET BLVD SUITE 110
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-248-4010
-----------------------------------------------------
Fax | 310-248-4001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9220 W SUNSET BLVD STE 110
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-248-4010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | RN525621
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | NPF 12752
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------