Provider Demographics
NPI:1639620156
Name:PENA, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
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 1:106 ALMOND CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-7525
Mailing Address - Country:US
Mailing Address - Phone:845-283-9197
Mailing Address - Fax:
Practice Address - Street 1:106 ALMOND CT
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-7525
Practice Address - Country:US
Practice Address - Phone:845-283-9197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326356-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse