Provider Demographics
NPI:1548021520
Name:MEDINA, KANDICE (FNP)
Entity type:Individual
Prefix:
First Name:KANDICE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 LA JOLLA BLVD APT 2G
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1708
Mailing Address - Country:US
Mailing Address - Phone:817-357-5187
Mailing Address - Fax:
Practice Address - Street 1:5050 LA JOLLA BLVD APT 2G
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-1708
Practice Address - Country:US
Practice Address - Phone:817-357-5187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA736924163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse