Provider Demographics
NPI:1508436817
Name:LANDIS, LAVON KAY (PMHNP)
Entity Type:Individual
Prefix:
First Name:LAVON
Middle Name:KAY
Last Name:LANDIS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 W IVY DR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-1221
Mailing Address - Country:US
Mailing Address - Phone:302-515-6935
Mailing Address - Fax:
Practice Address - Street 1:104C WILLIAMSPORT CIR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6400
Practice Address - Country:US
Practice Address - Phone:410-831-3899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0068895163W00000X
MDR204090163W00000X
DEL8-0010276363LP0808X
MDAC004066363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse