Healthcare Provider Details

I. General information

NPI: 1013328145
Provider Name (Legal Business Name): LYNETTE LICCINI LURIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 06/10/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RAF LAKENHEATH 48 MDG/SGHC UNIT 5115
APO AE
09461-5115
US

IV. Provider business mailing address

RAF LAKENHEATH 48 MDG/SGHC UNIT 5115
APO AE
09461-5115
US

V. Phone/Fax

Practice location:
  • Phone: 163-852-8124
  • Fax:
Mailing address:
  • Phone: 163-852-8124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number125787
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number125787
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: