Provider Demographics
NPI:1760245583
Name:PENA FONSECA, DANIELA
Entity Type:Individual
Prefix:MRS
First Name:DANIELA
Middle Name:
Last Name:PENA FONSECA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12470 NW 15TH PL APT 11308
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-5253
Mailing Address - Country:US
Mailing Address - Phone:754-308-0884
Mailing Address - Fax:
Practice Address - Street 1:12470 NW 15TH PL APT 11308
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-5253
Practice Address - Country:US
Practice Address - Phone:754-308-0884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24-135246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant