Provider Demographics
NPI:1962175935
Name:LOCKE, MADELINE KELLIE (APRN)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:KELLIE
Last Name:LOCKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:KELLIE
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3304 TOWNE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-1216
Mailing Address - Country:US
Mailing Address - Phone:618-599-9976
Mailing Address - Fax:
Practice Address - Street 1:659 PHILADELPHIA ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-5543
Practice Address - Country:US
Practice Address - Phone:901-728-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN249815163W00000X
TN32847363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNML7988679OtherDEA NUMBER