Provider Demographics
NPI:1356628747
Name:LAMBETH, MARLECIA LANEI (PA)
Entity Type:Individual
Prefix:
First Name:MARLECIA
Middle Name:LANEI
Last Name:LAMBETH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARLECIA
Other - Middle Name:LANEI
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 11553
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-4553
Mailing Address - Country:US
Mailing Address - Phone:240-965-4413
Mailing Address - Fax:240-542-2997
Practice Address - Street 1:4320 SEMINARY RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1535
Practice Address - Country:US
Practice Address - Phone:703-799-1688
Practice Address - Fax:703-799-4092
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004576208M00000X, 363AM0700X
VA0110006494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01031751Medicare PIN
231520Y5ZMedicare PIN