Provider Demographics
NPI:1245676097
Name:MEDINA, LAURA TIFFANY (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:TIFFANY
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 N LUZERNE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-1115
Mailing Address - Country:US
Mailing Address - Phone:917-975-1066
Mailing Address - Fax:
Practice Address - Street 1:4337 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-2143
Practice Address - Country:US
Practice Address - Phone:410-529-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23349225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF517OtherBLUE CROSS BLUE SHIELD OF MARYLAND