Provider Demographics
NPI:1053843268
Name:PENE, PECKY SUNDIATA (RN)
Entity Type:Individual
Prefix:
First Name:PECKY
Middle Name:SUNDIATA
Last Name:PENE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-4309
Mailing Address - Country:US
Mailing Address - Phone:240-764-9187
Mailing Address - Fax:
Practice Address - Street 1:8915 58TH AVE
Practice Address - Street 2:
Practice Address - City:BERWYN HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20740-4309
Practice Address - Country:US
Practice Address - Phone:240-764-9187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1040999163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse