Provider Demographics
NPI:1922021922
Name:MEDINA, WENDIE (APN)
Entity Type:Individual
Prefix:MRS
First Name:WENDIE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 DEER MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-5802
Mailing Address - Country:US
Mailing Address - Phone:217-483-7864
Mailing Address - Fax:217-483-7864
Practice Address - Street 1:512 DEER MEADOW DR
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-5802
Practice Address - Country:US
Practice Address - Phone:217-483-7864
Practice Address - Fax:217-483-7864
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005320364SR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SR0400XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ63994Medicare UPIN
ILK25340Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NO