Provider Demographics
NPI:1710296785
Name:PENA, CRYSTAL (CPM, LM)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6242 E MCLELLAN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-3638
Mailing Address - Country:US
Mailing Address - Phone:480-531-4015
Mailing Address - Fax:480-955-0980
Practice Address - Street 1:40 W BROWN RD # 108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3400
Practice Address - Country:US
Practice Address - Phone:480-567-9784
Practice Address - Fax:480-955-0980
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ187176B00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Yes176B00000XOther Service ProvidersMidwife