Provider Demographics
NPI:1356571715
Name:PENERA, REBECCA ANN (DPM)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:PENERA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:GROOTEGOED-PENERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:18080 BEACH BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1342
Mailing Address - Country:US
Mailing Address - Phone:714-841-5055
Mailing Address - Fax:
Practice Address - Street 1:18080 BEACH BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1342
Practice Address - Country:US
Practice Address - Phone:714-841-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5011213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist