Provider Demographics
NPI:1154553436
Name:MEDINA, REBECA
Entity type:Individual
Prefix:
First Name:REBECA
Middle Name:
Last Name:MEDINA
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 1:2973 MICKLE AVENUE
Mailing Address - Street 2:#2
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469
Mailing Address - Country:US
Mailing Address - Phone:347-449-5147
Mailing Address - Fax:
Practice Address - Street 1:2973 MICKLE AVENUE
Practice Address - Street 2:#2
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469
Practice Address - Country:US
Practice Address - Phone:347-449-5147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297780164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse