Provider Demographics
NPI:1740834902
Name:LOCKETT, LARRY LAMONT
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:LAMONT
Last Name:LOCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-2219
Mailing Address - Country:US
Mailing Address - Phone:313-772-1780
Mailing Address - Fax:
Practice Address - Street 1:37450 SCHOOLCRAFT RD STE 110
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1000
Practice Address - Country:US
Practice Address - Phone:734-458-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703108445164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse