Provider Demographics
NPI:1518401629
Name:MEDINA, FAWN ERIN (RN)
Entity Type:Individual
Prefix:MS
First Name:FAWN
Middle Name:ERIN
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 1:2920 WILSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469
Mailing Address - Country:US
Mailing Address - Phone:347-281-5313
Mailing Address - Fax:
Practice Address - Street 1:2920 WILSON AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469
Practice Address - Country:US
Practice Address - Phone:347-281-5313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY616240-1163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)