Provider Demographics
NPI:1073053716
Name:MEDINA, CHARLENNE C
Entity Type:Individual
Prefix:
First Name:CHARLENNE
Middle Name:C
Last Name:MEDINA
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 1:1431 OBISPO AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2504
Mailing Address - Country:US
Mailing Address - Phone:408-713-8199
Mailing Address - Fax:
Practice Address - Street 1:1431 OBISPO AVE APT 9
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2504
Practice Address - Country:US
Practice Address - Phone:408-713-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program