Provider Demographics
NPI:1134324163
Name:PENA, TIFFANY N (CRNA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:N
Last Name:PENA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 S. 23RD ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950
Mailing Address - Country:US
Mailing Address - Phone:772-468-4417
Mailing Address - Fax:
Practice Address - Street 1:9500 S DADELAND BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-2866
Practice Address - Country:US
Practice Address - Phone:305-468-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3315012367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3085252 00Medicaid
P00668172OtherRAILROAD MEDICARE
FLG4363OtherBCBS
FLAD862ZMedicare PIN