Healthcare Provider Details

I. General information

NPI: 1427894328
Provider Name (Legal Business Name): MISS STEFANI ANDREINA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12549 WESTHAVEN WAY
FORT MYERS FL
33913-8786
US

IV. Provider business mailing address

12549 WESTHAVEN WAY
FORT MYERS FL
33913-8786
US

V. Phone/Fax

Practice location:
  • Phone: 239-745-1933
  • Fax:
Mailing address:
  • Phone: 239-745-1933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN32484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: