Provider Demographics
NPI:1770865099
Name:MEDINA, MERCEDES M (LMT)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:M
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152521
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33915-2521
Mailing Address - Country:US
Mailing Address - Phone:239-240-3118
Mailing Address - Fax:
Practice Address - Street 1:1415 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-1208
Practice Address - Country:US
Practice Address - Phone:239-240-3118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA64329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist