Provider Demographics
NPI:1124110150
Name:LOVELOCK, WILFRED R (CRNA)
Entity type:Individual
Prefix:
First Name:WILFRED
Middle Name:R
Last Name:LOVELOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 RAMBLEBROOK ST
Mailing Address - Street 2:
Mailing Address - City:MALABAR
Mailing Address - State:FL
Mailing Address - Zip Code:32950-4210
Mailing Address - Country:US
Mailing Address - Phone:239-246-0512
Mailing Address - Fax:
Practice Address - Street 1:8040 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8367
Practice Address - Country:US
Practice Address - Phone:321-757-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA097420207L00000X
FL9296902367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1468924Medicaid
LA1468924Medicaid
MS04037074Medicare ID - Type UnspecifiedPROVIDER #