Provider Demographics
NPI:1124482484
Name:PENA FATULE, GRACE NABILA (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:NABILA
Last Name:PENA FATULE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:NABILA
Other - Last Name:MARTINEZ PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M D
Mailing Address - Street 1:8900 VAN WYCK EXPY
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2832
Mailing Address - Country:US
Mailing Address - Phone:718-206-6000
Mailing Address - Fax:
Practice Address - Street 1:8900 VAN WYCK EXPY
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2832
Practice Address - Country:US
Practice Address - Phone:210-206-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY307883-01207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease