Provider Demographics
NPI:1760869358
Name:MEDINA, STEPHANIE (ATC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 CROSSBOW CT
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-7117
Mailing Address - Country:US
Mailing Address - Phone:931-237-1404
Mailing Address - Fax:
Practice Address - Street 1:900 N JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2117
Practice Address - Country:US
Practice Address - Phone:931-237-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-03
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN287005207PS0010X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine