Provider Demographics
NPI:1881950574
Name:PENA, AMANDA INOLINDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:INOLINDA
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 1:1050 TREMONT ST
Mailing Address - Street 2:#613
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2171
Mailing Address - Country:US
Mailing Address - Phone:617-708-6666
Mailing Address - Fax:
Practice Address - Street 1:1050 TREMONT ST
Practice Address - Street 2:#613
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-2171
Practice Address - Country:US
Practice Address - Phone:617-708-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100041437581Medicaid