Provider Demographics
NPI:1689183428
Name:LOCKETT, MARY SHORTER
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SHORTER
Last Name:LOCKETT
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 1:4380 NW 36TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5539
Mailing Address - Country:US
Mailing Address - Phone:954-873-9606
Mailing Address - Fax:
Practice Address - Street 1:4380 NW 36TH ST
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5539
Practice Address - Country:US
Practice Address - Phone:954-873-9606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other