Healthcare Provider Details

I. General information

NPI: 1851877328
Provider Name (Legal Business Name): REXANNA TATLOCK AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 DOGWOOD TRL
SEYMOUR IN
47274-3411
US

IV. Provider business mailing address

2120 DOGWOOD TRL
SEYMOUR IN
47274-3411
US

V. Phone/Fax

Practice location:
  • Phone: 309-361-5148
  • Fax:
Mailing address:
  • Phone: 309-361-5148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71008415A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28204653A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: