Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | LM250 | AZ |
NPI | 1023775988 |
---|---|
Provider Name | Lisette Pena |
First Address | Gilbert, AZ 85295-5428 |
Second Address | Mesa, AZ 85206-5124 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/11/2021 |
Last Update Date | 25/11/2021 |