Provider Demographics
NPI:1063064426
Name:PENA POLANCO, VALERIE
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:PENA POLANCO
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 1:543 7TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-1929
Mailing Address - Country:US
Mailing Address - Phone:319-861-7895
Mailing Address - Fax:319-861-7677
Practice Address - Street 1:543 7TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52401-1929
Practice Address - Country:US
Practice Address - Phone:319-861-7895
Practice Address - Fax:319-861-7677
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.248240390200000X
IAMD-51350207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program