Basic Information
| Provider Information | |||||||||
| NPI: | 1508894908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCKE | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | DOROTHY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, GNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5525 RESEARCH PARK DRIVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486688650 | ||||||||
| FaxNumber: | 2486688650 | ||||||||
| Practice Location | |||||||||
| Address1: | 41100 FOX RUN | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483774804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486688650 | ||||||||
| FaxNumber: | 2486688651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 4704136295 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 223695886 | 01 | TRICARE NORTH | OTHER | 83-20307 | 01 | EVERCARE | OTHER |