Provider Demographics
NPI:1629641188
Name:MEDINA, ANNETTE BELTRAN
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:BELTRAN
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 1:1042 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3112
Mailing Address - Country:US
Mailing Address - Phone:213-318-1929
Mailing Address - Fax:
Practice Address - Street 1:11776 MARIPOSA RD STE 103104
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1622
Practice Address - Country:US
Practice Address - Phone:760-956-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN193384164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse