MEDICARE: KANDICE MEDINA FNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	736924	CA
2	163W00000X	Registered Nurse	736924	CA

General Provider Information

NPI Number	:	1548021520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANDICE MEDINA FNP

Provider Business Mailing Address
First Line	:	5050 LA JOLLA BLVD APT 2G
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-1708
Country	:	US
Telephone Number	:	817-357-5187
Fax Number	:

Provider Business Practice Location Address
First Line	:	5050 LA JOLLA BLVD APT 2G
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-1708
Country	:	US
Telephone Number	:	817-357-5187
Fax Number	:

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

Provider Enumeration Date	:	01/17/2024
Last Update Date	:	04/09/2026

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