Provider Demographics
NPI:1184981946
Name:PENA, NICOLE MARIE (LPN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PENA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 KING AVE
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2315
Mailing Address - Country:US
Mailing Address - Phone:631-732-6017
Mailing Address - Fax:
Practice Address - Street 1:14 KING AVE
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2315
Practice Address - Country:US
Practice Address - Phone:631-732-6017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306609164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse