Provider Demographics
NPI:1013621457
Name:MEDINA, VANESSA C
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:C
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:PO BOX 45281
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-5281
Mailing Address - Country:US
Mailing Address - Phone:505-677-0988
Mailing Address - Fax:505-808-4942
Practice Address - Street 1:10000 COORS BYP NW STE E1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4055
Practice Address - Country:US
Practice Address - Phone:505-677-0988
Practice Address - Fax:505-808-4942
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2022-08311041S0200X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical