Provider Demographics
NPI:1790371995
Name:PICKENS, JUSTIN ERIN
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ERIN
Last Name:PICKENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 STIRLING CENTER PL
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4856
Mailing Address - Country:US
Mailing Address - Phone:407-321-8230
Mailing Address - Fax:
Practice Address - Street 1:749 STIRLING CENTER PL
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4856
Practice Address - Country:US
Practice Address - Phone:407-321-8230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-12
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010438363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care