Healthcare Provider Details

I. General information

NPI: 1316599657
Provider Name (Legal Business Name): JOHANNA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43825 46TH ST W
LANCASTER CA
93536-2365
US

IV. Provider business mailing address

43825 46TH ST W
LANCASTER CA
93536-2365
US

V. Phone/Fax

Practice location:
  • Phone: 406-696-6766
  • Fax:
Mailing address:
  • Phone: 406-696-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number837431
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: