Provider Demographics
NPI:1891892105
Name:MEDINA ORTIZ, IVELISSE (TECHNICIAN)
Entity Type:Individual
Prefix:MRS
First Name:IVELISSE
Middle Name:
Last Name:MEDINA ORTIZ
Suffix:
Gender:F
Credentials:TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 8874
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767-8874
Mailing Address - Country:US
Mailing Address - Phone:787-893-1332
Mailing Address - Fax:
Practice Address - Street 1:5 CALLE CRISTOBAL COLON
Practice Address - Street 2:
Practice Address - City:YABUCOA
Practice Address - State:PR
Practice Address - Zip Code:00767-3328
Practice Address - Country:US
Practice Address - Phone:787-893-2280
Practice Address - Fax:787-893-6738
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3276183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3276OtherTECHNICIAN LINCENSE