Provider Demographics
NPI:1205571064
Name:PENA, NEREIDA (DO)
Entity type:Individual
Prefix:
First Name:NEREIDA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1173
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:WA
Mailing Address - Zip Code:98932-1173
Mailing Address - Country:US
Mailing Address - Phone:509-949-2095
Mailing Address - Fax:
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:509-949-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA21958207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program