Healthcare Provider Details

I. General information

NPI: 1700025285
Provider Name (Legal Business Name): MARY ELIZABETH MEDINA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 SIERRA ROSE DR STE B
RENO NV
89511-4010
US

IV. Provider business mailing address

13776 SWISS LANE
TRUCKEE CA CA
96161-3416
US

V. Phone/Fax

Practice location:
  • Phone: 775-453-1030
  • Fax: 775-319-1613
Mailing address:
  • Phone: 510-367-5383
  • Fax: 510-367-5383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number450481
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18684
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number826254
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: