Provider Demographics
NPI:1164856043
Name:MEDINA, ALICIA LAJUAN (CRNP)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:LAJUAN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5609 HONEYGO RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-3406
Mailing Address - Country:US
Mailing Address - Phone:410-908-8861
Mailing Address - Fax:
Practice Address - Street 1:5609 HONEYGO RIDGE CT
Practice Address - Street 2:
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21162-3406
Practice Address - Country:US
Practice Address - Phone:410-908-8861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR187630363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health