Healthcare Provider Details

I. General information

NPI: 1578565164
Provider Name (Legal Business Name): JODELLA LOCKLEAR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 LIVERMORE DR
PEMBROKE NC
28372-7282
US

IV. Provider business mailing address

17 LIVERMORE DR
PEMBROKE NC
28372-7282
US

V. Phone/Fax

Practice location:
  • Phone: 910-775-0210
  • Fax: 910-772-0110
Mailing address:
  • Phone: 910-775-0210
  • Fax: 910-775-0110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201788
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: