Healthcare Provider Details

I. General information

NPI: 1609320571
Provider Name (Legal Business Name): STEPHANIE MEDINA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1936 NORTH ST
NACOGDOCHES TX
75965-3940
US

IV. Provider business mailing address

1936 NORTH ST
NACOGDOCHES TX
75965-3940
US

V. Phone/Fax

Practice location:
  • Phone: 936-468-4550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000026122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: