Provider Demographics
NPI:1194017111
Name:PENA, RESHELLE DEANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RESHELLE
Middle Name:DEANNE
Last Name:PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RESHELLE
Other - Middle Name:DEANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:4150 N ARMENIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6448
Practice Address - Country:US
Practice Address - Phone:813-876-0914
Practice Address - Fax:813-876-9198
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 125802207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016091300Medicaid
FL016091300Medicaid