Provider Demographics
NPI:1093313033
Name:MEDINA, STEPHANIE LYN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYN
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 1:2349 N 83RD DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3742
Mailing Address - Country:US
Mailing Address - Phone:619-309-6824
Mailing Address - Fax:
Practice Address - Street 1:2349 N 83RD DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3742
Practice Address - Country:US
Practice Address - Phone:619-309-6824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ218387164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ218387OtherLICENCED PRACTICAL NURSE