Provider Demographics
NPI:1912583717
Name:LOCKHART, TINA RENEE'
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:RENEE'
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 1:6006 TOPPING LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-2419
Mailing Address - Country:US
Mailing Address - Phone:804-501-9138
Mailing Address - Fax:
Practice Address - Street 1:6006 TOPPING LN
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-2419
Practice Address - Country:US
Practice Address - Phone:804-501-9138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001189803163W00000X
VA0024183866363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse