Provider Demographics
NPI:1043959356
Name:PENA, MELANY
Entity Type:Individual
Prefix:
First Name:MELANY
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 1:16605 JARON DR
Mailing Address - Street 2:
Mailing Address - City:MANOR
Mailing Address - State:TX
Mailing Address - Zip Code:78653-5262
Mailing Address - Country:US
Mailing Address - Phone:512-576-0952
Mailing Address - Fax:
Practice Address - Street 1:1000 W COURT ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5978
Practice Address - Country:US
Practice Address - Phone:830-372-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXUTS0BJ2BI6N4Medicaid