Provider Demographics
NPI:1194964445
Name:PENA, NINA ROSE
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:ROSE
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 1:6255 W ARBY AVE UNIT 334
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-4659
Mailing Address - Country:US
Mailing Address - Phone:650-255-6384
Mailing Address - Fax:
Practice Address - Street 1:6255 W ARBY AVE UNIT 334
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-4659
Practice Address - Country:US
Practice Address - Phone:650-255-6384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13-0390174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist