Healthcare Provider Details

I. General information

NPI: 1578621595
Provider Name (Legal Business Name): BETTY LOCKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 E POPLAR AVE 641 EAST POPLAR
SELMER TN
38375-1828
US

IV. Provider business mailing address

641 E POPLAR AVE 641 EAST POPLAR
SELMER TN
38375-1828
US

V. Phone/Fax

Practice location:
  • Phone: 731-645-5753
  • Fax: 731-645-9885
Mailing address:
  • Phone: 731-645-5753
  • Fax: 731-645-9885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN 68445
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: