Healthcare Provider Details

I. General information

NPI: 1285058396
Provider Name (Legal Business Name): KELLY LOCKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NE INDEPENDENCE AVE
LEES SUMMIT MO
64086-5544
US

IV. Provider business mailing address

828 BIRCH ST
BUTLER MO
64730-1867
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-3288
  • Fax: 816-554-4263
Mailing address:
  • Phone: 660-424-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2009017324
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: