Provider Demographics
NPI:1790131589
Name:PENA, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:PENA
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 1:4506 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2732
Mailing Address - Country:US
Mailing Address - Phone:813-879-3530
Mailing Address - Fax:813-874-6608
Practice Address - Street 1:4506 N ARMENIA AVE
Practice Address - Street 2:2901 W. ST. ISABEL ST. STE # D
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2732
Practice Address - Country:US
Practice Address - Phone:813-879-3530
Practice Address - Fax:813-874-6608
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9288272363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1578924353OtherORGANIZATIONAL NPI