Healthcare Provider Details

I. General information

NPI: 1174018261
Provider Name (Legal Business Name): MALINE ANGELICA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2018
Last Update Date: 06/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E DEL MAR BLVD
PASADENA CA
91101-2714
US

IV. Provider business mailing address

4035 CLARET CT
PALMDALE CA
93552-5132
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-2016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number3130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: