1609484021 NPI number — MRS. KIARA DANIELLE PENA

Table of content: MRS. KIARA DANIELLE PENA (NPI 1609484021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609484021 NPI number — MRS. KIARA DANIELLE PENA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA
Provider First Name:
KIARA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DE JESUS
Provider Other First Name:
KIARA
Provider Other Middle Name:
DANIELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609484021
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 SUPERIOR AVE E STE 1800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44114-2500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-838-0410
Provider Business Mailing Address Fax Number:
317-520-8200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4016 WOODBINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44113-3286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-838-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106S00000X , with the licence number: RBT-20-126331 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)