Healthcare Provider Details

I. General information

NPI: 1427197888
Provider Name (Legal Business Name): ANNA LISA LICUD ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST., NW WHC SURGICAL CRITICAL CARE SERVICE SUITE 4B-42
WASHINGTON DC
20010-2975
US

IV. Provider business mailing address

9004 TEDDY RAE CT
SPRINGFIELD VA
22152-2644
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-7259
  • Fax:
Mailing address:
  • Phone: 571-594-3405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP1003124
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: