Basic Information
| Provider Information | |||||||||
| NPI: | 1710291323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ACNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | CREDENTIALING DEPT | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348050488 | ||||||||
| FaxNumber: | 8662506385 | ||||||||
| Practice Location | |||||||||
| Address1: | 8260 ATLEE RD | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231161844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047646300 | ||||||||
| FaxNumber: | 8047646562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2010 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 0024168889 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 0024168889 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.