Provider Demographics
NPI:1922790617
Name:BAEZ PENA, LADY C
Entity Type:Individual
Prefix:
First Name:LADY
Middle Name:C
Last Name:BAEZ 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 1:3810 BUCK LAKE RD APT 207
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-9447
Mailing Address - Country:US
Mailing Address - Phone:850-556-5073
Mailing Address - Fax:
Practice Address - Street 1:3810 BUCK LAKE RD APT 207
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32317-9447
Practice Address - Country:US
Practice Address - Phone:850-556-5073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1663-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant