Provider Demographics
NPI:1699256529
Name:MEDINA, IVANELLE DENISE (BS, MS)
Entity type:Individual
Prefix:MS
First Name:IVANELLE
Middle Name:DENISE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB.REPARTO MARQUEZ
Mailing Address - Street 2:CALLE 9 G-21
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612
Mailing Address - Country:US
Mailing Address - Phone:787-231-6399
Mailing Address - Fax:
Practice Address - Street 1:203 GALERIA DE SUCHVILLE
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966
Practice Address - Country:US
Practice Address - Phone:787-231-6399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist