Provider Demographics
NPI:1851877328
Name:TATLOCK, REXANNA (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:REXANNA
Middle Name:
Last Name:TATLOCK
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:812-375-3477
Practice Address - Street 1:2325 18TH ST STE 130
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5387
Practice Address - Country:US
Practice Address - Phone:812-379-2020
Practice Address - Fax:812-378-8267
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28204653A163W00000X
IN71008415A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021975Medicaid
IN000001214853OtherANTHEM PROVIDER NUMBER