Provider Demographics
NPI:1144454190
Name:PENA, FANNY
Entity type:Individual
Prefix:
First Name:FANNY
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 ATHERTON DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-4219
Mailing Address - Country:US
Mailing Address - Phone:917-439-3762
Mailing Address - Fax:
Practice Address - Street 1:2815 ATHERTON DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-4219
Practice Address - Country:US
Practice Address - Phone:917-439-3762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist