Healthcare Provider Details

I. General information

NPI: 1992465199
Provider Name (Legal Business Name): TAHRA S LOCK NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL AVE FL 9
SPRINGFIELD MO
65807-5210
US

IV. Provider business mailing address

PO BOX 802843
KANSAS CITY MO
64180-2843
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-5158
  • Fax: 417-269-4470
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021028370
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: