Provider Demographics
NPI:1629068507
Name:MEDLOCK, MARY ANNE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ANNE
Other - Last Name:LAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4549 RAYNOR COURT
Mailing Address - Street 2:OUTPATIENT ANESTHESIA SPECIALIST
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040
Mailing Address - Country:US
Mailing Address - Phone:513-204-5696
Mailing Address - Fax:877-284-4283
Practice Address - Street 1:2000 JOSEPH E. SANKER BOULEVARD
Practice Address - Street 2:THE UROLOGY CENTER
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212
Practice Address - Country:US
Practice Address - Phone:513-841-7600
Practice Address - Fax:513-841-7601
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH202765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0265681Medicaid
OHLA8218979Medicare PIN
OH8218978Medicare PIN
OH8208976Medicare PIN
OH0265681Medicaid