Healthcare Provider Details

I. General information

NPI: 1497129340
Provider Name (Legal Business Name): MICHELLE R MEDINA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE R MEDINA

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

V. Phone/Fax

Practice location:
  • Phone: 951-557-3015
  • Fax:
Mailing address:
  • Phone: 951-557-3015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015032210
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95011851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: