Provider Demographics
NPI:1962128165
Name:LOCKE, SHIRELL DENISE
Entity type:Individual
Prefix:
First Name:SHIRELL
Middle Name:DENISE
Last Name:LOCKE
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 1:2154 PIKE LAKE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-2483
Mailing Address - Country:US
Mailing Address - Phone:612-875-8596
Mailing Address - Fax:
Practice Address - Street 1:2154 PIKE LAKE DR APT 3
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-2483
Practice Address - Country:US
Practice Address - Phone:612-875-8596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN92185420210311374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide