Provider Demographics
NPI:1629852199
Name:MEDINA, ANGEL MARIE
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:MARIE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20311 LAPPANS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOONSBORO
Mailing Address - State:MD
Mailing Address - Zip Code:21713-2085
Mailing Address - Country:US
Mailing Address - Phone:301-799-1098
Mailing Address - Fax:
Practice Address - Street 1:20311 LAPPANS RD STE 100
Practice Address - Street 2:
Practice Address - City:BOONSBORO
Practice Address - State:MD
Practice Address - Zip Code:21713-2085
Practice Address - Country:US
Practice Address - Phone:301-799-1098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC007935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily