Healthcare Provider Details

I. General information

NPI: 1942948120
Provider Name (Legal Business Name): EMMA LAUREN LIETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MERCANTILE LN
LARGO MD
20774-5374
US

IV. Provider business mailing address

1221 MERCANTILE LN
LARGO MD
20774-5374
US

V. Phone/Fax

Practice location:
  • Phone: 301-618-5500
  • Fax:
Mailing address:
  • Phone: 301-618-7184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008741
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: