Provider Demographics
NPI:1013795608
Name:MEDINA, IVELISSE (SLPA)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11993 KAJETAN LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7153
Mailing Address - Country:US
Mailing Address - Phone:407-335-8578
Mailing Address - Fax:
Practice Address - Street 1:11993 KAJETAN LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7153
Practice Address - Country:US
Practice Address - Phone:407-335-8578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI2200261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech