Provider Demographics
NPI:1275004145
Name:MEDLOCK, RAYVEION LAQUITA (PNP)
Entity Type:Individual
Prefix:MS
First Name:RAYVEION
Middle Name:LAQUITA
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CEDAR WALK UNIT 2115
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-7922
Mailing Address - Country:US
Mailing Address - Phone:562-481-4850
Mailing Address - Fax:
Practice Address - Street 1:40 CEDAR WALK UNIT 2115
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-7922
Practice Address - Country:US
Practice Address - Phone:562-481-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010266363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics