Provider Demographics
NPI:1508645334
Name:PENA, YISEL
Entity Type:Individual
Prefix:
First Name:YISEL
Middle Name:
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 1:13335 SW 57TH TER APT 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-1250
Mailing Address - Country:US
Mailing Address - Phone:786-616-5991
Mailing Address - Fax:
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:786-616-5991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI45932390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program