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General NPI Number Information
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NPI Number | 1144559188
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Entity Type | Individual
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Provider Name | JESSICA MEDINA
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Gender | Female
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Dates
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Enumeration Date | 12/22/2009
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Last Update Date | 12/22/2009
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Provider Practice Location Address
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Address Line | 1150 RESERVOIR AVE
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City | CRANSTON
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State | RI
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Zip | 02920-6068
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Country | US
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Telephone | 401-943-8151
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Fax |
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Provider Business Mailing Address
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Address Line | 14 EATON ST
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City | NORTH SMITHFIELD
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State | RI
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Zip | 02896-7806
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Country | US
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Telephone | 401-580-2488
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODTG00546
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4752
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License Number State | MA
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