Provider Demographics
NPI:1598247876
Name:PENA, ANA LIZA
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:LIZA
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 1:6009 MARTINDALE CIR APT 138
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2214
Mailing Address - Country:US
Mailing Address - Phone:620-453-0026
Mailing Address - Fax:
Practice Address - Street 1:6009 MARTINDALE CIR APT 138
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2214
Practice Address - Country:US
Practice Address - Phone:620-453-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty