Provider Demographics
NPI:1861454415
Name:MEDINA, DEANNA SUE (OTR/L)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:SUE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:SUE
Other - Last Name:PEKAREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:88 NDG/SGHJ
Mailing Address - Street 2:4881 SUGAR MAPLE DR
Mailing Address - City:WRIGHT-PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-257-8718
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:673 MDOS/SGOY
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-580-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106340225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist