Healthcare Provider Details

I. General information

NPI: 1124516851
Provider Name (Legal Business Name): PRINCESS J LOCK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 N ORANGE BLOSSOM TRL
KISSIMMEE FL
34744-1373
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 407-380-0302
  • Fax: 407-380-5127
Mailing address:
  • Phone: 407-222-4543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPRN9237351
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: