Provider Demographics
NPI:1255591137
Name:PENA, ELSI L
Entity type:Individual
Prefix:MRS
First Name:ELSI
Middle Name:L
Last Name: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 1:511 NW 82ND AVE APT 413
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3993
Mailing Address - Country:US
Mailing Address - Phone:305-264-5816
Mailing Address - Fax:
Practice Address - Street 1:3510 BISCAYNE BLVD # 300
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-3840
Practice Address - Country:US
Practice Address - Phone:305-576-1234
Practice Address - Fax:305-571-2020
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692290200Medicaid