Provider Demographics
NPI:1750407342
Name:LOCKHART, KAREN ANN
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:ANN
Last Name:LOCKHART
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:ANN LOCKHART
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1257
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:WA
Mailing Address - Zip Code:98576-1257
Mailing Address - Country:US
Mailing Address - Phone:360-446-7113
Mailing Address - Fax:360-446-0069
Practice Address - Street 1:12445 118TH AVE SE
Practice Address - Street 2:MOBILE BUISNESS OFFICE
Practice Address - City:RAINIER
Practice Address - State:WA
Practice Address - Zip Code:98576-9792
Practice Address - Country:US
Practice Address - Phone:360-446-7113
Practice Address - Fax:360-446-0069
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00001600124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5900675Medicaid