Healthcare Provider Details

I. General information

NPI: 1770064313
Provider Name (Legal Business Name): KATHERINE IVONNE MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W SANTA ANA BLVD
SANTA ANA CA
92701-4558
US

IV. Provider business mailing address

600 W SANTA ANA BLVD
SANTA ANA CA
92701-4558
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax:
Mailing address:
  • Phone: 714-953-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number124506
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: