Provider Demographics
NPI:1295501526
Name:PENILLA, MICHAEL (LVN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:PENILLA
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-2227
Mailing Address - Country:US
Mailing Address - Phone:619-786-4206
Mailing Address - Fax:
Practice Address - Street 1:8898 CLAIREMONT MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1147
Practice Address - Country:US
Practice Address - Phone:619-966-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN685275164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse