Provider Demographics
NPI:1679179709
Name:PENA, ADELBERTO J JR (RN)
Entity Type:Individual
Prefix:
First Name:ADELBERTO
Middle Name:J
Last Name:PENA
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 ENSIGN RD NE APT 2-202
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5409
Mailing Address - Country:US
Mailing Address - Phone:406-274-7063
Mailing Address - Fax:
Practice Address - Street 1:3724 ENSIGN RD NE APT 2-202
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5409
Practice Address - Country:US
Practice Address - Phone:406-274-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61092920163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical