Provider Demographics
NPI:1063295772
Name:MEDLOCK, KIRSTEN
Entity type:Individual
Prefix:
First Name:KIRSTEN
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 1:501 WILSON LN
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-5216
Mailing Address - Country:US
Mailing Address - Phone:304-636-9326
Mailing Address - Fax:
Practice Address - Street 1:8488 CLARKSBURG RD
Practice Address - Street 2:
Practice Address - City:VOLGA
Practice Address - State:WV
Practice Address - Zip Code:26238-7541
Practice Address - Country:US
Practice Address - Phone:304-472-9259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant