Provider Demographics
NPI:1083975171
Name:ALI, MEDINA
Entity Type:Individual
Prefix:
First Name:MEDINA
Middle Name:
Last Name:ALI
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 1:7513 MAPLE AVE
Mailing Address - Street 2:APT#605
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-4903
Mailing Address - Country:US
Mailing Address - Phone:240-486-9611
Mailing Address - Fax:
Practice Address - Street 1:7513 MAPLE AVE
Practice Address - Street 2:APT#605
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-4903
Practice Address - Country:US
Practice Address - Phone:240-486-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA-400-599-907-810374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide