Provider Demographics
NPI:1467034520
Name:PENA, ANDREA (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 LAKE OAKS RD
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1616
Mailing Address - Country:US
Mailing Address - Phone:903-571-5142
Mailing Address - Fax:
Practice Address - Street 1:6901 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7910
Practice Address - Country:US
Practice Address - Phone:254-751-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
302691174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN