Provider Demographics
NPI:1548253867
Name:PENA, HOLLY BETH (ARNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:BETH
Last Name:PENA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:MILES-PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1919 LINCOLN WAY STE 415
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2527
Mailing Address - Country:US
Mailing Address - Phone:208-625-4595
Mailing Address - Fax:208-625-4596
Practice Address - Street 1:1919 LINCOLN WAY STE 415
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2527
Practice Address - Country:US
Practice Address - Phone:208-625-4595
Practice Address - Fax:208-625-4596
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007003363L00000X
IDNP-690A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1548253867Medicaid
WA9645045Medicaid
WA8854405Medicare ID - Type Unspecified