Provider Demographics
NPI:1366863235
Name:MEDINA, CANDY (RN)
Entity Type:Individual
Prefix:MRS
First Name:CANDY
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 WASHINGTON ST
Mailing Address - Street 2:1301 WEST WASHINGTON STREET
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-8846
Mailing Address - Country:US
Mailing Address - Phone:575-882-6101
Mailing Address - Fax:575-882-6926
Practice Address - Street 1:1301 WASHINGTON ST
Practice Address - Street 2:1301 WEST WASHINGTON STREET
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021-8846
Practice Address - Country:US
Practice Address - Phone:575-882-6101
Practice Address - Fax:575-882-6926
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR53615163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool