Healthcare Provider Details

I. General information

NPI: 1760869358
Provider Name (Legal Business Name): STEPHANIE MEDINA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2015
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N JOHN R WOODEN DR
WEST LAFAYETTE IN
47907-2117
US

IV. Provider business mailing address

4421 CROSSBOW CT
WEST LAFAYETTE IN
47906-7117
US

V. Phone/Fax

Practice location:
  • Phone: 931-237-1404
  • Fax:
Mailing address:
  • Phone: 931-237-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number287005
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: