MEDICARE: MISS KIM MARIE MEDINA RN

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	163W00000X	Registered Nurse	658888	NY
2	363LP0200X	Pediatric Nurse Practitioner	APRN11044480	FL
3	163W00000X	Registered Nurse	RN9541541	FL

General Provider Information

NPI Number	:	1588912315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KIM MARIE MEDINA RN

Provider Business Mailing Address
First Line	:	13024 CORDELIA LN UNIT 105
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-5168
Country	:	US
Telephone Number	:	347-331-1079
Fax Number	:

Provider Business Practice Location Address
First Line	:	13024 CORDELIA LN UNIT 105
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-5168
Country	:	US
Telephone Number	:	347-331-1079
Fax Number	:

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

Provider Enumeration Date	:	08/28/2012
Last Update Date	:	01/16/2026

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