Provider Demographics
NPI:1760882187
Name:LOCKHART, PATTY JO
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:JO
Last Name:LOCKHART
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 1:1419 E SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4151
Mailing Address - Country:US
Mailing Address - Phone:307-703-1111
Mailing Address - Fax:
Practice Address - Street 1:1419 E SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4151
Practice Address - Country:US
Practice Address - Phone:307-703-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 251S00000X
WY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1760882187Medicaid