Individual
REXANNA TATLOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
AGPCNP-BC
Contact information
Practice address
4035 MIMOSA DR, COLUMBUS, IN 47201-7200
(812) 375-6358
(812) 375-6373
Mailing address
PO BOX 781076, DETROIT, MI 48278-1076
(317) 528-4800
(317) 865-1479
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28204653A
IN
363LA2200X
Adult Health Nurse Practitioner
Primary
71008415A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001214853
ANTHEM PROVIDER NUMBER
IN
05
—
300021975
—
IN
Enumeration date
07/17/2018
Last updated
09/06/2024
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