Basic Information
| Provider Information | |||||||||
| NPI: | 1124578984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOCKE | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 N OAK AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317835857 | ||||||||
| FaxNumber: | 9315266760 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 N CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317835353 | ||||||||
| FaxNumber: | 9317834994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2016 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 3116 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 3116 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | Q024834 | 05 | TN | MEDICAID | 7100448340 | 05 | KY | MEDICAID | 6080296 | 01 | TN | BCBS | OTHER |