Healthcare Provider Details

I. General information

NPI: 1780150607
Provider Name (Legal Business Name): LAUREN LOCKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN DEYOUNG

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13963 MORSE ST
CEDAR LAKE IN
46303-9639
US

IV. Provider business mailing address

13963 MORSE ST
CEDAR LAKE IN
46303-9639
US

V. Phone/Fax

Practice location:
  • Phone: 219-374-5555
  • Fax:
Mailing address:
  • Phone: 219-374-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28210044A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008561A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: