Provider Demographics
NPI:1376708834
Name:MEDINA, KRISTEN MICHELE (CPNP)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:MICHELE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FORBES ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1527
Mailing Address - Country:US
Mailing Address - Phone:410-263-6363
Mailing Address - Fax:
Practice Address - Street 1:200 FORBES ST STE 200
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1527
Practice Address - Country:US
Practice Address - Phone:410-263-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR136622363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics