Provider Demographics
NPI:1043078389
Name:MEDINA, DRYSSI NICOLLE (F02241104)
Entity Type:Individual
Prefix:MRS
First Name:DRYSSI
Middle Name:NICOLLE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:F02241104
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2496 BLOWING BREEZE AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-6156
Mailing Address - Country:US
Mailing Address - Phone:689-323-2820
Mailing Address - Fax:
Practice Address - Street 1:2496 BLOWING BREEZE AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-6156
Practice Address - Country:US
Practice Address - Phone:689-323-2820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF02241104363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty