Provider Demographics
NPI:1033305925
Name:LICCIARDI, PAULA S (FNP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:S
Last Name:LICCIARDI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W JUDGE PEREZ DR
Mailing Address - Street 2:
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-4906
Mailing Address - Country:US
Mailing Address - Phone:504-669-6638
Mailing Address - Fax:
Practice Address - Street 1:410 W JUDGE PEREZ DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-4906
Practice Address - Country:US
Practice Address - Phone:504-249-5187
Practice Address - Fax:504-304-9951
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN073519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19D1083407OtherCLIA CERTIFICATE OF WAVIER
LA3A675DD86Medicare PIN