Provider Demographics
NPI:1366114308
Name:LOCK, LESA RENEE (APRN)
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:RENEE
Last Name:LOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 HIGHWAY 95 STE 200
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6057
Mailing Address - Country:US
Mailing Address - Phone:928-758-1175
Mailing Address - Fax:
Practice Address - Street 1:2000 HIGHWAY 95 STE 200
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6057
Practice Address - Country:US
Practice Address - Phone:928-758-1175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ264824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner