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General NPI Number Information
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NPI Number | 1225738545
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Entity Type | Individual
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Provider Name | KELLY MARIA MEDINA
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Gender | Female
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Dates
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Enumeration Date | 03/06/2023
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | 2801 NE 213TH ST STE 1001
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City | AVENTURA
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State | FL
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Zip | 33180-1265
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Country | US
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Telephone | 305-466-9111
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Fax | 305-466-9127
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Provider Business Mailing Address
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Address Line | 3450 SW 124TH AVE
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City | MIRAMAR
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State | FL
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Zip | 33027-2941
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Country | US
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Telephone |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9119158
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License Number State | FL
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