Provider Demographics
NPI:1558903757
Name:MEDINA, DIANA ESTHER
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:ESTHER
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 1:43449 EDITH WAY
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-1927
Mailing Address - Country:US
Mailing Address - Phone:951-448-2767
Mailing Address - Fax:
Practice Address - Street 1:31225 WATER AVE
Practice Address - Street 2:
Practice Address - City:NUEVO
Practice Address - State:CA
Practice Address - Zip Code:92567-9760
Practice Address - Country:US
Practice Address - Phone:951-448-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF4997424OtherDRIVER LICENSE