Provider Demographics
NPI:1942072418
Name:MEDINA IBARRA, PRISCILLA LISETT (FNP-BC)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:LISETT
Last Name:MEDINA IBARRA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 WILLOW PL
Mailing Address - Street 2:
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280-2510
Mailing Address - Country:US
Mailing Address - Phone:661-229-9240
Mailing Address - Fax:
Practice Address - Street 1:1674 WILLOW PL
Practice Address - Street 2:
Practice Address - City:WASCO
Practice Address - State:CA
Practice Address - Zip Code:93280-2510
Practice Address - Country:US
Practice Address - Phone:661-229-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025920363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner