Provider Demographics
NPI:1841039120
Name:JENICCA, MEDINA ISMAEL (MANAGING DIRECTOR)
Entity type:Individual
Prefix:
First Name:MEDINA
Middle Name:ISMAEL
Last Name:JENICCA
Suffix:
Gender:F
Credentials:MANAGING DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29819 CEDAR WAXWING DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33545-3885
Mailing Address - Country:US
Mailing Address - Phone:605-496-4441
Mailing Address - Fax:
Practice Address - Street 1:29819 CEDAR WAXWING DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33545-3885
Practice Address - Country:US
Practice Address - Phone:605-496-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL24000226826376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker