Provider Demographics
NPI:1295073773
Name:PICKENS, LAVETTA ANNETTE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:LAVETTA
Middle Name:ANNETTE
Last Name:PICKENS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10535 LANARK ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1232
Mailing Address - Country:US
Mailing Address - Phone:313-642-0478
Mailing Address - Fax:
Practice Address - Street 1:611 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2273
Practice Address - Country:US
Practice Address - Phone:313-832-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704221867363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care