Provider Demographics
NPI:1639439433
Name:MEDLOCK, DANIEL D (APNP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:D
Last Name:MEDLOCK
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1978
Mailing Address - Country:US
Mailing Address - Phone:262-687-2956
Mailing Address - Fax:262-687-2014
Practice Address - Street 1:1320 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1978
Practice Address - Country:US
Practice Address - Phone:262-687-2956
Practice Address - Fax:262-687-2014
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9750363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1412-226OtherWI STATE LICENSE