Healthcare Provider Details

I. General information

NPI: 1356937874
Provider Name (Legal Business Name): STACIE LOCKHART RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4961 RICE LAKE RD STE 106
DULUTH MN
55803-8439
US

IV. Provider business mailing address

10467 93RD AVE N
MAPLE GROVE MN
55369-4112
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-4105
  • Fax:
Mailing address:
  • Phone: 651-707-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2148782
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: