Provider Demographics
NPI:1891062642
Name:HURLOCKER, TONI LYNN (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TONI
Middle Name:LYNN
Last Name:HURLOCKER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:LYNN
Other - Last Name:DAMEWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:GLIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97443-0458
Mailing Address - Country:US
Mailing Address - Phone:541-643-1638
Mailing Address - Fax:541-496-0703
Practice Address - Street 1:20172 N UMPQUA HWY
Practice Address - Street 2:
Practice Address - City:GLIDE
Practice Address - State:OR
Practice Address - Zip Code:97443-9620
Practice Address - Country:US
Practice Address - Phone:541-496-0298
Practice Address - Fax:541-496-0703
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150169NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500697442Medicaid