Provider Demographics
NPI:1285862748
Name:MEDINA POELINIZ, CLARISA (APN)
Entity type:Individual
Prefix:
First Name:CLARISA
Middle Name:
Last Name:MEDINA POELINIZ
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 S 7TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-9375
Mailing Address - Country:US
Mailing Address - Phone:815-562-6976
Mailing Address - Fax:815-562-9786
Practice Address - Street 1:903 S 7TH ST STE C
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-9375
Practice Address - Country:US
Practice Address - Phone:815-562-6976
Practice Address - Fax:815-562-9786
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.317970163W00000X
IL209.007592363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376793031OtherMEDICARE PTAN
IL376796015OtherMEDICARE PTAN