Provider Demographics
NPI:1306481247
Name:MEDINA, DYMPHNA I (LMT)
Entity type:Individual
Prefix:MRS
First Name:DYMPHNA
Middle Name:I
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5264 W GOLDEN VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-6358
Mailing Address - Country:US
Mailing Address - Phone:520-780-2015
Mailing Address - Fax:
Practice Address - Street 1:210 W CONTINENTAL RD STE 130A
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85622-3546
Practice Address - Country:US
Practice Address - Phone:520-906-8358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18456225000000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter