Provider Demographics
NPI:1194316877
Name:MEDLOCK, NIA NICHELLE ADA
Entity type:Individual
Prefix:
First Name:NIA
Middle Name:NICHELLE ADA
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 1:1351 E 51ST ST APT 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-4852
Mailing Address - Country:US
Mailing Address - Phone:323-963-0086
Mailing Address - Fax:
Practice Address - Street 1:691 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-5003
Practice Address - Country:US
Practice Address - Phone:323-963-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health