Provider Demographics
NPI:1134091424
Name:MEDINA VISEREP, AGRIPINA
Entity type:Individual
Prefix:
First Name:AGRIPINA
Middle Name:
Last Name:MEDINA VISEREP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 BARKLEY AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-3137
Mailing Address - Country:US
Mailing Address - Phone:551-204-8625
Mailing Address - Fax:
Practice Address - Street 1:155 WILLOWBROOK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7033
Practice Address - Country:US
Practice Address - Phone:551-204-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-18
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174N00000X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty