Basic Information
| Provider Information | |||||||||
| NPI: | 1285114264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | LEYBIS | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91 AMES ST APT C299 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021243051 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021181951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174252030 | ||||||||
| FaxNumber: | 6174252031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2018 | ||||||||
| LastUpdateDate: | 08/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN2324873 | MA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.