Provider Demographics
NPI:1306198361
Name:MEDINA, FRAILLA
Entity Type:Individual
Prefix:
First Name:FRAILLA
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 1:100-05 ROOSEVELT AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-878-4103
Mailing Address - Fax:718-803-6440
Practice Address - Street 1:100-05 ROOSEVELT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-878-4103
Practice Address - Fax:718-803-6440
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031204-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist