Provider Demographics
NPI:1144829581
Name:VILLALBA PENA, DIANA CAROLINA (SA-C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:CAROLINA
Last Name:VILLALBA PENA
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S LUNA CT APT 111
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-7564
Mailing Address - Country:US
Mailing Address - Phone:954-554-2445
Mailing Address - Fax:
Practice Address - Street 1:555 S LUNA CT APT 111
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-7564
Practice Address - Country:US
Practice Address - Phone:954-554-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-398246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant