Healthcare Provider Details

I. General information

NPI: 1477910099
Provider Name (Legal Business Name): MRS. PATRICIA LICAUSI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3148 MAIN STREET
FREDERICA DE
19946
US

IV. Provider business mailing address

3148 MAIN ST.
FREDERICA DE
19946
US

V. Phone/Fax

Practice location:
  • Phone: 302-724-9113
  • Fax:
Mailing address:
  • Phone: 302-538-4183
  • Fax: 302-724-9113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: