MEDICARE: ANDREA JENNYS SUSTACHE MEDINA

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	235Z00000X	Speech-Language Pathologist	117625	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770222028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA JENNYS SUSTACHE MEDINA

Provider Business Mailing Address
First Line	:	3813 PERIWINKLE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6046
Country	:	US
Telephone Number	:	787-983-4456
Fax Number	:

Provider Business Practice Location Address
First Line	:	3813 PERIWINKLE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6046
Country	:	US
Telephone Number	:	787-983-4456
Fax Number	:

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

Provider Enumeration Date	:	06/02/2022
Last Update Date	:	06/02/2022

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