Provider Demographics
NPI:1124330329
Name:MEDINA, MICHELLE (CRNA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DELLAVALLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:100 ROUTE 59
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4927
Mailing Address - Country:US
Mailing Address - Phone:845-357-5775
Mailing Address - Fax:845-357-5777
Practice Address - Street 1:1 COOPER PLZ DEPT OF
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1461
Practice Address - Country:US
Practice Address - Phone:856-342-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY581615-1367500000X
NJ26NJ00295000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ226569Medicare PIN