Healthcare Provider Details

I. General information

NPI: 1508436817
Provider Name (Legal Business Name): LAVON KAY LANDIS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104C WILLIAMSPORT CIR
SALISBURY MD
21804-6400
US

IV. Provider business mailing address

727 W IVY DR
SEAFORD DE
19973-1221
US

V. Phone/Fax

Practice location:
  • Phone: 410-831-3899
  • Fax:
Mailing address:
  • Phone: 302-515-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberL8-0010276
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAC004066
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0068895
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR204090
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: