Healthcare Provider Details

I. General information

NPI: 1801548250
Provider Name (Legal Business Name): NICOLE G. MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 EL CAMINO REAL STE 213
TUSTIN CA
92780-3656
US

IV. Provider business mailing address

1751 COLORADO BLVD # 180
LOS ANGELES CA
90041-1348
US

V. Phone/Fax

Practice location:
  • Phone: 714-805-6510
  • Fax:
Mailing address:
  • Phone: 213-379-5371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number135401
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: