Healthcare Provider Details

I. General information

NPI: 1023588126
Provider Name (Legal Business Name): MICHELLE LYNN MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 12/08/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 SANTA FE DR
ENCINITAS CA
92024-5142
US

IV. Provider business mailing address

38400 BOB WILSON DR
SAN DIEGO CA
92134-0001
US

V. Phone/Fax

Practice location:
  • Phone: 760-633-6501
  • Fax:
Mailing address:
  • Phone: 619-750-1817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberNMW235883
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberNMW235883
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: