Provider Demographics
NPI:1124516851
Name:LOCK, PRINCESS J (APRN)
Entity type:Individual
Prefix:
First Name:PRINCESS
Middle Name:J
Last Name:LOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:407-222-4543
Mailing Address - Fax:
Practice Address - Street 1:2711 N ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1373
Practice Address - Country:US
Practice Address - Phone:407-380-0302
Practice Address - Fax:407-380-5127
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9237351363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101437000Medicaid
FLOP567OtherMEDICARE HF