Provider Demographics
NPI:1689681926
Name:PENA, PATRICIA L (RD/LD)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:L
Last Name:PENA
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 S SUGAR RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-3693
Mailing Address - Country:US
Mailing Address - Phone:956-380-0798
Mailing Address - Fax:956-380-0550
Practice Address - Street 1:3204 S SUGAR RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-3693
Practice Address - Country:US
Practice Address - Phone:956-380-0798
Practice Address - Fax:956-380-0550
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03891133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004460404Medicaid
TX004460405Medicaid
TX004460403Medicaid