Provider Demographics
NPI:1396153748
Name:MEDINA, STEPHANIA (ATC, LAT)
Entity type:Individual
Prefix:
First Name:STEPHANIA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 REINHARDT CIR
Mailing Address - Street 2:
Mailing Address - City:WALESKA
Mailing Address - State:GA
Mailing Address - Zip Code:30183-2981
Mailing Address - Country:US
Mailing Address - Phone:770-720-5821
Mailing Address - Fax:
Practice Address - Street 1:7300 REINHARDT CIR
Practice Address - Street 2:
Practice Address - City:WALESKA
Practice Address - State:GA
Practice Address - Zip Code:30183-2981
Practice Address - Country:US
Practice Address - Phone:770-720-5821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0022932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer