Provider Demographics
NPI:1902385461
Name:SIERRA MEDINA, MARIANGIE
Entity Type:Individual
Prefix:
First Name:MARIANGIE
Middle Name:
Last Name:SIERRA 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 1:411 SPIKE CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-4027
Mailing Address - Country:US
Mailing Address - Phone:863-800-4787
Mailing Address - Fax:
Practice Address - Street 1:411 SPIKE CT
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-4027
Practice Address - Country:US
Practice Address - Phone:863-800-4787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022005800Medicaid