Provider Demographics
NPI:1649549015
Name:LOCK, SHARON LEE (CHA II)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:LEE
Last Name:LOCK
Suffix:
Gender:F
Credentials:CHA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 PUNGUK STREET
Mailing Address - Street 2:
Mailing Address - City:GOLOVIN
Mailing Address - State:AK
Mailing Address - Zip Code:99762
Mailing Address - Country:US
Mailing Address - Phone:907-779-3311
Mailing Address - Fax:907-779-3312
Practice Address - Street 1:59 PUNGUK STREET
Practice Address - Street 2:
Practice Address - City:GOLOVIN
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-779-3311
Practice Address - Fax:907-779-3312
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCHAII172V00000X
AK04-008 EFD-HA1126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK04-008 DFT-HA1Medicaid