Provider Demographics
NPI:1972255347
Name:QUEEN, LAVERNE
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:
Last Name:QUEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 WEDGEWOOD PL APT A
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2305
Mailing Address - Country:US
Mailing Address - Phone:240-432-8331
Mailing Address - Fax:
Practice Address - Street 1:1400 FAIRMONT ST NW APT 107
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-6901
Practice Address - Country:US
Practice Address - Phone:202-798-9374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant