Healthcare Provider Details

I. General information

NPI: 1770937344
Provider Name (Legal Business Name): TERRI MEDLOCK MSN WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 3RD AVE
JASPER IN
47546-3636
US

IV. Provider business mailing address

201 SPRING MEADOW CIR
SALEM IN
47167-9430
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-2233
  • Fax:
Mailing address:
  • Phone: 812-620-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number28114242A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: