Provider Demographics
NPI:1992470579
Name:PENA-MAM, DORA ENID (RN)
Entity type:Individual
Prefix:
First Name:DORA
Middle Name:ENID
Last Name:PENA-MAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 MAKALAPA GATE RD
Mailing Address - Street 2:
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860-4479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1253 MAKALAPA GATE RD
Practice Address - Street 2:
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860-4479
Practice Address - Country:US
Practice Address - Phone:978-413-7424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-15
Last Update Date:2021-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2275341163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty