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:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical