Provider Demographics
NPI:1972843282
Name:PENA, MARISOL A (RPSGT)
Entity Type:Individual
Prefix:MRS
First Name:MARISOL
Middle Name:A
Last Name:PENA
Suffix:
Gender:F
Credentials:RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 NEW BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4146
Mailing Address - Country:US
Mailing Address - Phone:732-486-8602
Mailing Address - Fax:732-486-8517
Practice Address - Street 1:235 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-4146
Practice Address - Country:US
Practice Address - Phone:732-486-8602
Practice Address - Fax:732-486-8517
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ49FW00019600261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic