Provider Demographics
NPI:1932970035
Name:MEDINA, AMANDA M (FNP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:MEDINA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:GOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4045 BROOKDALE LN UNIT 7
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-4186
Mailing Address - Country:US
Mailing Address - Phone:715-225-0332
Mailing Address - Fax:
Practice Address - Street 1:4045 BROOKDALE LN UNIT 7
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45440-4186
Practice Address - Country:US
Practice Address - Phone:715-225-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0035595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily