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General NPI Number Information
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NPI Number | 1609343698
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Entity Type | Individual
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Provider Name | VANESSA GAMMILL LICKSON APRN
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Gender | Female
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Dates
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Enumeration Date | 10/27/2018
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 16875 NE CAYSON ST
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City | BLOUNTSTOWN
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State | FL
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Zip | 32424-2209
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Country | US
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Telephone | 850-674-2244
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Fax | 850-674-2249
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Provider Business Mailing Address
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Address Line | 403 E 11TH ST
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City | PANAMA CITY
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State | FL
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Zip | 32401-3409
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Country | US
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Telephone | 850-747-5599
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 9301316
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 11000074
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APRN11000074
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License Number State | FL
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