Provider Demographics
NPI:1811559412
Name:PENA, YUDAISY E (LVN)
Entity Type:Individual
Prefix:
First Name:YUDAISY
Middle Name:E
Last Name:PENA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SAINT ANDREWS LN
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 SAINT ANDREWS LN
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8905
Practice Address - Country:US
Practice Address - Phone:956-442-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX348585164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790847531Medicaid