MEDICARE: KATHLEEN LICKFELDT NP-C

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	363LA2200X	Adult Health Nurse Practitioner	9288359	FL
2	363L00000X	Nurse Practitioner	SP029917	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	V68RY	OTHER	FL	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821457870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN LICKFELDT NP-C

Provider Business Mailing Address
First Line	:	3803 W CHESTER PIKE STE 160
Second Line	:
City	:	NEWTOWN SQUARE
State	:	PA
Zip	:	19073-2336
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	930 GERMANTOWN PIKE
Second Line	:
City	:	PLYMOUTH MEETING
State	:	PA
Zip	:	19462-7400
Country	:	US
Telephone Number	:	484-476-1000
Fax Number	:

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

Provider Enumeration Date	:	02/18/2016
Last Update Date	:	10/15/2024

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