Healthcare Provider Details

I. General information

NPI: 1396156188
Provider Name (Legal Business Name): KAHLEEL LOCKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 LAFAYETTES LNDG
JONESBORO GA
30238-6702
US

IV. Provider business mailing address

1415 HIGHWAY 85 N STE 310-379
FAYETTEVILLE GA
30214-7738
US

V. Phone/Fax

Practice location:
  • Phone: 646-752-8144
  • Fax:
Mailing address:
  • Phone: 646-752-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407106
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP297748
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number754102
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN297748
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: