Provider Demographics
NPI:1013485739
Name:PENA, DOMYS E (APRN)
Entity Type:Individual
Prefix:
First Name:DOMYS
Middle Name:E
Last Name:PENA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7592
Mailing Address - Country:US
Mailing Address - Phone:321-332-6947
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:1834 N ALAFAYA TRL UNIT 3
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4716
Practice Address - Country:US
Practice Address - Phone:407-627-0062
Practice Address - Fax:407-674-7346
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9369566363LF0000X
FLAPRN11000415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102393500Medicaid