Healthcare Provider Details

I. General information

NPI: 1063485449
Provider Name (Legal Business Name): ANN LAUREL LICHT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3019
US

IV. Provider business mailing address

5900 BAYVIEW CIR S
GULFPORT FL
33707-3930
US

V. Phone/Fax

Practice location:
  • Phone: 863-680-7214
  • Fax: 866-264-8519
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberME83569
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License NumberME83569
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: