MEDICARE: MARCELLA MEDINA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	LL60780256	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LL60780256	OTHER	WA	WA STATE DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1518524545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCELLA MEDINA

Provider Business Mailing Address
First Line	:	6014 N RUBY ST APT 31
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208-1151
Country	:	US
Telephone Number	:	570-267-5288
Fax Number	:

Provider Business Practice Location Address
First Line	:	4202 S REGAL ST
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99223-7738
Country	:	US
Telephone Number	:	509-789-3800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2019
Last Update Date	:	05/24/2019

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Directions to “ MARCELLA MEDINA ” Practice Location

Language	Start Address	Practice Location

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