Basic Information
| Provider Information | |||||||||
| NPI: | 1063064426 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENA POLANCO | ||||||||
| FirstName: | VALERIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1127 EUCLID AVE APT 804 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441151612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027845432 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2351 E 22ND ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441153111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168616200 | ||||||||
| FaxNumber: | 2163637490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2019 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 57.248240 | OH | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.