Provider Demographics
NPI:1942809132
Name:MEDINA, ANDRIANNA MICHELLE
Entity Type:Individual
Prefix:MISS
First Name:ANDRIANNA
Middle Name:MICHELLE
Last Name: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 1:1855 TOM BOLT DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4217
Mailing Address - Country:US
Mailing Address - Phone:915-202-8568
Mailing Address - Fax:
Practice Address - Street 1:1855 TOM BOLT DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4217
Practice Address - Country:US
Practice Address - Phone:915-202-8568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX917251163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse