Healthcare Provider Details

I. General information

NPI: 1851908438
Provider Name (Legal Business Name): MARIA MEDINILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4064 SW 95TH AVE
MIAMI FL
33165-5240
US

IV. Provider business mailing address

4064 SW 95TH AVE
MIAMI FL
33165-5240
US

V. Phone/Fax

Practice location:
  • Phone: 786-709-8024
  • Fax:
Mailing address:
  • Phone: 786-709-8024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI3322
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: