Provider Demographics
NPI:1396238093
Name:LOCK, NICOLE ELLYN (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELLYN
Last Name:LOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 S GREENE ST # N4WICU
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1544
Mailing Address - Country:US
Mailing Address - Phone:410-328-6716
Mailing Address - Fax:410-706-5103
Practice Address - Street 1:22 S GREENE ST # N4WICU
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6716
Practice Address - Fax:410-706-5103
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116034904208000000X
MDH0100583208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics