Healthcare Provider Details

I. General information

NPI: 1194524926
Provider Name (Legal Business Name): JANNETTE MEDINA PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 E TREMONT AVE
BRONX NY
10460-2306
US

IV. Provider business mailing address

76 BROOKSIDE AVE UNIT 23
CHESTER NY
10918-7502
US

V. Phone/Fax

Practice location:
  • Phone: 917-297-6842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberF-383560
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: