Provider Demographics
NPI:1477328433
Name:PENA, ELIZABETH MICHELLE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MICHELLE
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 S VILLAGE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3696
Mailing Address - Country:US
Mailing Address - Phone:909-599-8222
Mailing Address - Fax:
Practice Address - Street 1:957 S VILLAGE OAKS DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3696
Practice Address - Country:US
Practice Address - Phone:909-599-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator