Provider Demographics
NPI:1376930404
Name:LOCKE, MARY ROSE
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ROSE
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 1:8200 ROBERTS DR
Mailing Address - Street 2:STE 450
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-4115
Mailing Address - Country:US
Mailing Address - Phone:770-485-3723
Mailing Address - Fax:678-803-6944
Practice Address - Street 1:1620 MULKEY RD
Practice Address - Street 2:STE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1171
Practice Address - Country:US
Practice Address - Phone:770-953-3331
Practice Address - Fax:770-739-9609
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN198225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily