Provider Demographics
NPI:1982727160
Name:MEDLOCK, REGINA ANN
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:ANN
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 1:2101 POJOAQUE CT
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9369
Mailing Address - Country:US
Mailing Address - Phone:505-359-1221
Mailing Address - Fax:505-359-1075
Practice Address - Street 1:300 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-5914
Practice Address - Country:US
Practice Address - Phone:505-359-1221
Practice Address - Fax:505-359-1075
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator