Healthcare Provider Details

I. General information

NPI: 1710291323
Provider Name (Legal Business Name): DOROTHY ANNE MEDINA ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 ATLEE RD EMERGENCY DEPT
MECHANICSVILLE VA
23116-1844
US

IV. Provider business mailing address

38935 ANN ARBOR RD CREDENTIALING DEPT
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 804-764-6300
  • Fax: 804-764-6562
Mailing address:
  • Phone: 734-805-0488
  • Fax: 866-250-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024168889
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024168889
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: