Provider Demographics
NPI:1639442478
Name:MEDLOCK, LAUREL J
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:J
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 E CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-3642
Mailing Address - Country:US
Mailing Address - Phone:559-600-6736
Mailing Address - Fax:
Practice Address - Street 1:142 E CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-3642
Practice Address - Country:US
Practice Address - Phone:559-600-6736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator