Provider Demographics
NPI:1174041198
Name:PENA, ELIZABETH (ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-4952
Mailing Address - Country:US
Mailing Address - Phone:559-909-4693
Mailing Address - Fax:
Practice Address - Street 1:1000 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4112
Practice Address - Country:US
Practice Address - Phone:575-538-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer