1114602786 NPI number — DESSARAE LOCKHART NURSE PRACTITIONER

Table of content: DESSARAE LOCKHART NURSE PRACTITIONER (NPI 1114602786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114602786 NPI number — DESSARAE LOCKHART NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOCKHART
Provider First Name:
DESSARAE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORBITT
Provider Other First Name:
DESSARAE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114602786
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2637 N 400 E # 164
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84414-2240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2304 HIGHWAY 121
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76021-5985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-970-6817
Provider Business Practice Location Address Fax Number:
844-803-4513
Provider Enumeration Date:
06/20/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  F05230482 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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