Provider Demographics
NPI:1164179297
Name:MEDINA, ELIZABETH
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
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 1:1001 UNIVERSITY AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-4261
Mailing Address - Country:US
Mailing Address - Phone:917-365-4152
Mailing Address - Fax:
Practice Address - Street 1:1001 UNIVERSITY AVE APT 2C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-4261
Practice Address - Country:US
Practice Address - Phone:917-365-4152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator