Provider Demographics
NPI:1659481158
Name:LOCKETT, TRACY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:LOCKETT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4591 SE HANOVER CT
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-2458
Mailing Address - Country:US
Mailing Address - Phone:772-288-4876
Mailing Address - Fax:
Practice Address - Street 1:2676 SW IMMANUEL DR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-2738
Practice Address - Country:US
Practice Address - Phone:772-219-4444
Practice Address - Fax:772-219-0550
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2706482363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306930300Medicaid