Provider Demographics
NPI:1750852000
Name:PENA, ASHLEY JEAN (BS)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JEAN
Last Name:PENA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 NW 14TH PL
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-1614
Mailing Address - Country:US
Mailing Address - Phone:405-924-3461
Mailing Address - Fax:
Practice Address - Street 1:1020 NW 14TH PL
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-1614
Practice Address - Country:US
Practice Address - Phone:405-924-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKU082651687171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator