Basic Information
| Provider Information | |||||||||
| NPI: | 1104038769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AUD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SLIFER | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003288602 | ||||||||
| FaxNumber: | 9522853980 | ||||||||
| Practice Location | |||||||||
| Address1: | 23822 VALENCIA BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913555303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612533277 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 0000791 | CO | N | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 231H00000X | AU3469 | CA | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.