Provider Demographics
NPI:1720665359
Name:PENA, DIANA MARLENE (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARLENE
Last Name:PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-780-2315
Mailing Address - Fax:702-895-1014
Practice Address - Street 1:1524 PINTO LN FL 3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4195
Practice Address - Country:US
Practice Address - Phone:702-944-2828
Practice Address - Fax:702-944-2852
Is Sole Proprietor?:No
Enumeration Date:2021-03-28
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NV26113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program