Provider Demographics
NPI:1477986750
Name:PENA, ANITA (LVN)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 OLIVEWOOD TER
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-2738
Mailing Address - Country:US
Mailing Address - Phone:619-608-4723
Mailing Address - Fax:
Practice Address - Street 1:604 OLIVEWOOD TER
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113
Practice Address - Country:US
Practice Address - Phone:619-608-4723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 265426164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse