MEDICARE: MELLANIE MEDINA N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024168478	VA

General Provider Information

NPI Number	:	1184958514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELLANIE MEDINA N.P.

Provider Business Mailing Address
First Line	:	5980 9TH ST BLDG 1259
Second Line	:
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-5509
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5980 9TH ST BLDG 1259
Second Line	:
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-5509
Country	:	US
Telephone Number	:	571-231-1210
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2009
Last Update Date	:	06/23/2025

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