Healthcare Provider Details

I. General information

NPI: 1689419970
Provider Name (Legal Business Name): VICTORIA ELENA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 X ST
SACRAMENTO CA
95817-2200
US

IV. Provider business mailing address

3000 NIKOL ST
SACRAMENTO CA
95826-4128
US

V. Phone/Fax

Practice location:
  • Phone: 916-816-2409
  • Fax:
Mailing address:
  • Phone: 916-816-2409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: