Healthcare Provider Details

I. General information

NPI: 1114602786
Provider Name (Legal Business Name): DESSARAE LOCKHART NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESSARAE CORBITT

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/20/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2304 HIGHWAY 121
BEDFORD TX
76021-5985
US

IV. Provider business mailing address

2637 N 400 E # 164
NORTH OGDEN UT
84414-2240
US

V. Phone/Fax

Practice location:
  • Phone: 214-970-6817
  • Fax: 844-803-4513
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF05230482
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: