=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790315489
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEISHLA MEDINA MPHE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2020
-----------------------------------------------------
Last Update Date | 01/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE. RAFAEL CORDERO, ESQUINA TROCHE APT. 1025
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-745-0340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | URBANIZACION LOS SUENOS #65 CIUDAD JARDIN
-----------------------------------------------------
City | GURABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-696-8888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number | 1025
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------