Provider Demographics
NPI:1982012688
Name:MEDLOCK, SHARETT
Entity Type:Individual
Prefix:
First Name:SHARETT
Middle Name:
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 1:308 N COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:MART
Mailing Address - State:TX
Mailing Address - Zip Code:76664-1111
Mailing Address - Country:US
Mailing Address - Phone:254-640-2752
Mailing Address - Fax:
Practice Address - Street 1:308 N COMMERCE ST
Practice Address - Street 2:
Practice Address - City:MART
Practice Address - State:TX
Practice Address - Zip Code:76664-1111
Practice Address - Country:US
Practice Address - Phone:254-640-2752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX317359164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse