Healthcare Provider Details

I. General information

NPI: 1972591964
Provider Name (Legal Business Name): AMY LOCKHERT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E WASHINGTON ST
KENNETT MO
63857-2041
US

IV. Provider business mailing address

105 E WASHINGTON ST
KENNETT MO
63857-2041
US

V. Phone/Fax

Practice location:
  • Phone: 573-888-1137
  • Fax: 573-888-0920
Mailing address:
  • Phone: 573-888-1137
  • Fax: 573-888-0920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2000160888
License Number StateMO

VIII. Authorized Official

Name: RENEE SPARKS
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-888-1137