Provider Demographics
NPI:1184008278
Name:LOCKE, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:LOCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST FL STREET2
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:978-466-3208
Mailing Address - Fax:978-840-1680
Practice Address - Street 1:225 NEW LANCASTER ROAD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-4958
Practice Address - Country:US
Practice Address - Phone:978-466-3208
Practice Address - Fax:978-840-1680
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2266517363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110110519AMedicaid
MAS400306956Medicare PIN