Provider Demographics
NPI:1407749369
Name:PICKETT, LESLY (LVN)
Entity type:Individual
Prefix:
First Name:LESLY
Middle Name:
Last Name:PICKETT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13307 DALMATIAN WAY
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5312
Mailing Address - Country:US
Mailing Address - Phone:760-713-5802
Mailing Address - Fax:
Practice Address - Street 1:13307 DALMATIAN WAY
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5312
Practice Address - Country:US
Practice Address - Phone:760-713-5802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291868261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty