MEDICARE: ALYSSA KATHERINE LOCKHART RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R 208871-6	MN

General Provider Information

NPI Number	:	1083007512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA KATHERINE LOCKHART RN

Provider Business Mailing Address
First Line	:	12205 YANCY ST NE
Second Line	:	UNIT B
City	:	BLAINE
State	:	MN
Zip	:	55449-5746
Country	:	US
Telephone Number	:	320-250-6623
Fax Number	:

Provider Business Practice Location Address
First Line	:	10077 DOGWOOD ST NW
Second Line	:	SUITE 110
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55448-5286
Country	:	US
Telephone Number	:	763-792-9471
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2015
Last Update Date	:	03/09/2015

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