Provider Demographics
NPI:1750100442
Name:PENA, HENRY JUNIOR (DNP, AGNP-C)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:JUNIOR
Last Name:PENA
Suffix:
Gender:M
Credentials:DNP, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 HILLCROFT AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-2148
Mailing Address - Country:US
Mailing Address - Phone:616-856-1992
Mailing Address - Fax:
Practice Address - Street 1:2060 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3029
Practice Address - Country:US
Practice Address - Phone:616-475-8446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG07240076363LG0600X, 363LA2200X
MI4704238185163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse