Provider Demographics
NPI:1245761386
Name:MEDINA, PRISCILA ANDREA (ATC)
Entity Type:Individual
Prefix:MS
First Name:PRISCILA
Middle Name:ANDREA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8611 BONAIRE BAY LN
Mailing Address - Street 2:APT 301
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-1796
Mailing Address - Country:US
Mailing Address - Phone:305-801-7617
Mailing Address - Fax:
Practice Address - Street 1:134 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8101
Practice Address - Country:US
Practice Address - Phone:305-801-7617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL44532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer