Provider Demographics
NPI:1346829579
Name:PENA-PLACENCIA, DEYANIRA (INDEPENDENT CONTRACT)
Entity Type:Individual
Prefix:
First Name:DEYANIRA
Middle Name:
Last Name:PENA-PLACENCIA
Suffix:
Gender:F
Credentials:INDEPENDENT CONTRACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-8108
Mailing Address - Country:US
Mailing Address - Phone:973-405-8595
Mailing Address - Fax:973-779-4804
Practice Address - Street 1:4 MONROE ST # 2A
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-8108
Practice Address - Country:US
Practice Address - Phone:973-405-8595
Practice Address - Fax:973-779-4804
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes331L00000XSuppliersBlood Bank
Provider Identifiers
StateIdentifier IDID TypeIssuer
NGOtherINSURANCE STATUS PENDING