Provider Demographics
NPI:1386440089
Name:PENA DIAZ, MARIA FERNANDA (SA-C)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:FERNANDA
Last Name:PENA DIAZ
Suffix:
Gender:
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1768 WHITE WATER CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-7779
Mailing Address - Country:US
Mailing Address - Phone:407-361-1820
Mailing Address - Fax:
Practice Address - Street 1:1768 WHITE WATER CT
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-7779
Practice Address - Country:US
Practice Address - Phone:407-361-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-22
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-574246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant