Provider Demographics
NPI:1255969176
Name:MEDALLA, PATRICIA ANNE TANAEL (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:PATRICIA ANNE
Middle Name:TANAEL
Last Name:MEDALLA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30927 UNION CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-2547
Mailing Address - Country:US
Mailing Address - Phone:510-402-7368
Mailing Address - Fax:
Practice Address - Street 1:38627 CHERRY LN APT 81
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4270
Practice Address - Country:US
Practice Address - Phone:510-402-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty