Healthcare Provider Details

I. General information

NPI: 1154057297
Provider Name (Legal Business Name): ALISHA LICKWAR WHNP-BC, MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2022
Last Update Date: 07/30/2022
Certification Date: 07/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GARFIELD DR NE STE 1
WARREN OH
44483-5557
US

IV. Provider business mailing address

2230 SALT SPRINGS RD
WARREN OH
44481-9766
US

V. Phone/Fax

Practice location:
  • Phone: 330-372-1828
  • Fax:
Mailing address:
  • Phone: 330-394-4597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number0031856
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: