Provider Demographics
NPI:1710570916
Name:PENA, ELY (MS)
Entity Type:Individual
Prefix:
First Name:ELY
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:ELISABEHT
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:11835 FARMERS BLVD APT 106
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-4004
Mailing Address - Country:US
Mailing Address - Phone:917-272-2014
Mailing Address - Fax:
Practice Address - Street 1:11835 FARMERS BLVD APT 106
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-4004
Practice Address - Country:US
Practice Address - Phone:917-272-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2594179174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY550493040OtherPASSPORT
NY127-572-899OtherDRIVER LICENSE
NY127572899OtherDRIVER LICENSE