Provider Demographics
NPI:1376031674
Name:LOCKETT, DEANNA S
Entity Type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:S
Last Name:LOCKETT
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 1:12625 PAGE HILL CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-0012
Mailing Address - Country:US
Mailing Address - Phone:260-348-4738
Mailing Address - Fax:
Practice Address - Street 1:12625 PAGE HILL CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-0012
Practice Address - Country:US
Practice Address - Phone:260-348-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3500053430Medicaid