MEDICARE: DR. NICOLE DORA LICATO DNP, RN, FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5013426	NC

General Provider Information

NPI Number	:	1710598644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE DORA LICATO DNP, RN, FNP-BC

Provider Business Mailing Address
First Line	:	20 MAYO ST APT A2
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27603-1532
Country	:	US
Telephone Number	:	908-902-9580
Fax Number	:

Provider Business Practice Location Address
First Line	:	7200 CREEDMOOR RD STE 208
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-1711
Country	:	US
Telephone Number	:	919-701-5157
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2020
Last Update Date	:	08/13/2020

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