Healthcare Provider Details

I. General information

NPI: 1669396784
Provider Name (Legal Business Name): BIANCA ANN MEDINA LSAA, CNA, RMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 RANDOLPH RD SE
ALBUQUERQUE NM
87106-4230
US

IV. Provider business mailing address

9301 INDIAN SCHOOL RD NE STE 204&205
ALBUQUERQUE NM
87112-2884
US

V. Phone/Fax

Practice location:
  • Phone: 505-257-5760
  • Fax:
Mailing address:
  • Phone: 505-416-4351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: