Provider Demographics
NPI:1023588126
Name:MEDINA, MICHELLE LYNN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
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 1:38400 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-0001
Mailing Address - Country:US
Mailing Address - Phone:619-750-1817
Mailing Address - Fax:
Practice Address - Street 1:354 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5142
Practice Address - Country:US
Practice Address - Phone:760-633-6501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW235883176B00000X, 367A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program