Provider Demographics
NPI:1386265627
Name:LOCKETT, LILLIE MAE
Entity type:Individual
Prefix:
First Name:LILLIE
Middle Name:MAE
Last Name:LOCKETT
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 1:1025 RITCHIE AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 RITCHIE AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-624-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider