Healthcare Provider Details

I. General information

NPI: 1366863235
Provider Name (Legal Business Name): CANDY MEDINA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2013
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WASHINGTON ST 1301 WEST WASHINGTON STREET
ANTHONY NM
88021-8846
US

IV. Provider business mailing address

1301 WASHINGTON ST 1301 WEST WASHINGTON STREET
ANTHONY NM
88021-8846
US

V. Phone/Fax

Practice location:
  • Phone: 575-882-6101
  • Fax: 575-882-6926
Mailing address:
  • Phone: 575-882-6101
  • Fax: 575-882-6926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR53615
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: