Provider Demographics
NPI:1306482500
Name:LOCKLEAR, KIMALISA
Entity type:Individual
Prefix:
First Name:KIMALISA
Middle Name:
Last Name:LOCKLEAR
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 1:3637 CAPE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4457
Mailing Address - Country:US
Mailing Address - Phone:910-491-1760
Mailing Address - Fax:910-491-1764
Practice Address - Street 1:3637 CAPE CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4457
Practice Address - Country:US
Practice Address - Phone:910-491-1760
Practice Address - Fax:910-491-1764
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012570363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner