Healthcare Provider Details

I. General information

NPI: 1679489702
Provider Name (Legal Business Name): GRACE MEDINA PEREZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10391 CORPORATE DR
REDLANDS CA
92374-4509
US

IV. Provider business mailing address

10391 CORPORATE DR
REDLANDS CA
92374-4509
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax: 909-825-7084
Mailing address:
  • Phone: 909-825-7084
  • Fax: 909-825-7084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN500123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: