MEDICARE: MRS. MARY MEDINA PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1057358	TX

General Provider Information

NPI Number	:	1710641089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY MEDINA PMHNP

Provider Business Mailing Address
First Line	:	13353 CITRUS LN
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75035-0024
Country	:	US
Telephone Number	:	972-400-5060
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 COMMUNITY AVE
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071-2535
Country	:	US
Telephone Number	:	972-547-5232
Fax Number	:

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

Provider Enumeration Date	:	10/23/2021
Last Update Date	:	10/23/2021

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