Basic Information
| Provider Information | |||||||||
| NPI: | 1770054678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | ELYSE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 W A ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956203437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076351600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 131 W A ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956203437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076351600 | ||||||||
| FaxNumber: | 2098886909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95009728 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.