Basic Information
| Provider Information | |||||||||
| NPI: | 1740211416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOCKE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 635 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852757787 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 635 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852757787 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363LP0200X | F381345 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02284251 | 05 | NY | MEDICAID |