Provider Demographics
NPI:1790069748
Name:MEDINA, GLENDA FABIOLA (MSN-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:FABIOLA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MSN-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 FANNIN ST STE 1878
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2752
Mailing Address - Country:US
Mailing Address - Phone:713-441-5189
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST STE 1878
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2752
Practice Address - Country:US
Practice Address - Phone:713-441-5189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX702304364SA2100X
TXAP117917363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX326773403Medicaid