Provider Demographics
NPI:1932972072
Name:MEDINA, LADONNA (BCEP)
Entity Type:Individual
Prefix:
First Name:LADONNA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:BCEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-5705
Mailing Address - Country:US
Mailing Address - Phone:707-310-0863
Mailing Address - Fax:
Practice Address - Street 1:1409 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5705
Practice Address - Country:US
Practice Address - Phone:707-310-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician