Provider Demographics
NPI:1043906753
Name:MEDINA, VIVIAN DEL CARMEN (APRN)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:DEL CARMEN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3927 S TRAPANI DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3496
Mailing Address - Country:US
Mailing Address - Phone:904-521-0994
Mailing Address - Fax:
Practice Address - Street 1:14 OFFICE PARK DR STE 6
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3830
Practice Address - Country:US
Practice Address - Phone:407-299-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11025782363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily