Healthcare Provider Details

I. General information

NPI: 1700780384
Provider Name (Legal Business Name): MEDINA ILJAZI FNP-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 BLOSSOM WAY
SOUTHINGTON CT
06489-1879
US

IV. Provider business mailing address

48 BLOSSOM WAY
SOUTHINGTON CT
06489-1879
US

V. Phone/Fax

Practice location:
  • Phone: 860-620-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number194920
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: