Provider Demographics
NPI:1699658260
Name:PENA, STACY ANN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
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 1:430 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5640
Mailing Address - Country:US
Mailing Address - Phone:216-409-5261
Mailing Address - Fax:
Practice Address - Street 1:9083 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6462
Practice Address - Country:US
Practice Address - Phone:216-409-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-30
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.006463175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist