Provider Demographics
NPI:1205893583
Name:LOCKWOOD, JUDITH ANN (CNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29048
Mailing Address - Street 2:MSC874
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-2199
Mailing Address - Country:US
Mailing Address - Phone:505-338-3851
Mailing Address - Fax:
Practice Address - Street 1:330 UNIT C
Practice Address - Street 2:PASEL DEL PUEBLO SUR
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5219
Practice Address - Country:US
Practice Address - Phone:575-758-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2013-04-26
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-31
Provider Licenses
StateLicense IDTaxonomies
NMR2123363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
343404002Medicare PIN
S44097Medicare UPIN
NM260657YLKBMedicare PIN