Healthcare Provider Details

I. General information

NPI: 1265750194
Provider Name (Legal Business Name): GINGER NICHOLE LOCKLEAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 CANDY PARK RD
PEMBROKE NC
28372-9129
US

IV. Provider business mailing address

812 CANDY PARK RD
PEMBROKE NC
28372-9129
US

V. Phone/Fax

Practice location:
  • Phone: 910-521-0201
  • Fax: 910-521-0773
Mailing address:
  • Phone: 910-521-0201
  • Fax: 910-521-0773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2013-00348
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number201300348
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: