Provider Demographics
NPI:1376293308
Name:MEDINA, MICHELLE TATIANA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:TATIANA
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 1:2801 MEMORIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114
Mailing Address - Country:US
Mailing Address - Phone:954-604-8992
Mailing Address - Fax:
Practice Address - Street 1:6823 SAINT CHARLES AVE BLDG 92
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5665
Practice Address - Country:US
Practice Address - Phone:504-314-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11017323363LP0808X
LA1376293308363LP0808X
LA229032363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health