Healthcare Provider Details

I. General information

NPI: 1487597233
Provider Name (Legal Business Name): ISABEL LICATA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N CHARLES ST
BALTIMORE MD
21210
US

IV. Provider business mailing address

914 S DECKER AVE
BALTIMORE MD
21224-4939
US

V. Phone/Fax

Practice location:
  • Phone: 410-435-0100
  • Fax:
Mailing address:
  • Phone: 732-618-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: