Provider Demographics
NPI:1306238530
Name:PICKETT-EVANS, LEESA
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:
Last Name:PICKETT-EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 CORPORATE DR
Mailing Address - Street 2:SUITE 700
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-2230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8201 CORPORATE DR
Practice Address - Street 2:SUITE 700
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-2230
Practice Address - Country:US
Practice Address - Phone:202-635-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR141254163W00000X
DCRN67414163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse