Provider Demographics
NPI:1831613744
Name:PENA, WANDALY
Entity type:Individual
Prefix:
First Name:WANDALY
Middle Name:
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 1:812 E 231ST ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-4568
Mailing Address - Country:US
Mailing Address - Phone:646-229-9947
Mailing Address - Fax:
Practice Address - Street 1:429 E 148TH ST FL 1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4128
Practice Address - Country:US
Practice Address - Phone:718-585-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty