Provider Demographics
NPI:1871795823
Name:MEDINA, SANDRA ANGELICA
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:ANGELICA
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 1:250 N HAMBLEDON AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-5323
Mailing Address - Country:US
Mailing Address - Phone:626-581-8684
Mailing Address - Fax:
Practice Address - Street 1:2900 E DEL MAR BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-4375
Practice Address - Country:US
Practice Address - Phone:626-795-9901
Practice Address - Fax:626-356-2503
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA40294167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator