Provider Demographics
NPI:1043793417
Name:PENA, LISA NICOLE (APN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:PENA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 S YORK RD
Mailing Address - Street 2:
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-2631
Mailing Address - Country:US
Mailing Address - Phone:630-521-9700
Mailing Address - Fax:630-521-9797
Practice Address - Street 1:440 S YORK RD
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-2631
Practice Address - Country:US
Practice Address - Phone:630-521-9700
Practice Address - Fax:630-521-9797
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily