Provider Demographics
NPI:1477165629
Name:PENA, LISA C (CPM, LM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:PENA
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1042
Mailing Address - Street 2:
Mailing Address - City:MESILLA
Mailing Address - State:NM
Mailing Address - Zip Code:88046-1042
Mailing Address - Country:US
Mailing Address - Phone:575-496-5042
Mailing Address - Fax:
Practice Address - Street 1:2110 CALLE DE SAN ALBINO
Practice Address - Street 2:
Practice Address - City:MESILLA
Practice Address - State:NM
Practice Address - Zip Code:88046-8804
Practice Address - Country:US
Practice Address - Phone:575-496-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20005R176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife