Provider Demographics
NPI:1770112104
Name:PENA, AMANDA MARIE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 RICHLEE CT APT 1S
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3625
Mailing Address - Country:US
Mailing Address - Phone:718-749-3498
Mailing Address - Fax:
Practice Address - Street 1:1245 S CEDAR CREST BLVD STE 201
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6258
Practice Address - Country:US
Practice Address - Phone:610-402-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0485625207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology