Provider Demographics
NPI:1972016335
Name:MEDINA LOPEZ, ELIANNE MARIE
Entity Type:Individual
Prefix:MISS
First Name:ELIANNE
Middle Name:MARIE
Last Name:MEDINA LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ELIANNE
Other - Middle Name:M
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 607087
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-7087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 CALLE ISABEL
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730-3722
Practice Address - Country:US
Practice Address - Phone:787-848-3073
Practice Address - Fax:787-812-0301
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14004104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$Medicaid