Provider Demographics
NPI:1639787377
Name:DECENA, PEPITO JIMENEZ JR (LPN)
Entity Type:Individual
Prefix:
First Name:PEPITO
Middle Name:JIMENEZ
Last Name:DECENA
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5117
Mailing Address - Country:US
Mailing Address - Phone:571-508-7144
Mailing Address - Fax:
Practice Address - Street 1:13800 COPPERMINE RD # 124-A
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-6163
Practice Address - Country:US
Practice Address - Phone:571-508-7144
Practice Address - Fax:703-935-0898
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002093395364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0000Medicaid