Basic Information
| Provider Information | |||||||||
| NPI: | 1396238093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOCK | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ELLYN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 LEE STREET | ||||||||
| Address2: | MAILBOX 800386 | ||||||||
| City: | CHARLOTTSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245429 | ||||||||
| FaxNumber: | 4349242816 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067217005 | ||||||||
| FaxNumber: | 7064463546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2018 | ||||||||
| LastUpdateDate: | 07/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0116034904 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.