Provider Demographics
NPI:1154837557
Name:MEDINA, MICHELLE (LAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 WEBSTER ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-3534
Mailing Address - Country:US
Mailing Address - Phone:415-525-2837
Mailing Address - Fax:
Practice Address - Street 1:729 EL CERRITO PLZ
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-4022
Practice Address - Country:US
Practice Address - Phone:510-408-6120
Practice Address - Fax:510-408-6120
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16910171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist