Provider Demographics
NPI:1770612533
Name:MEDINA, NICOLE JENNYS (NONE)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JENNYS
Last Name:MEDINA
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12450 SW FISCHER RD UNIT 225
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2378
Mailing Address - Country:US
Mailing Address - Phone:503-516-9172
Mailing Address - Fax:
Practice Address - Street 1:12450 SW FISCHER RD UNIT 225
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-2378
Practice Address - Country:US
Practice Address - Phone:503-516-9172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator