Provider Demographics
NPI:1275398372
Name:LICON, DANIEL RAY JR (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:RAY
Last Name:LICON
Suffix:JR
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 SHERIDAN AVE
Mailing Address - Street 2:48
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926
Mailing Address - Country:US
Mailing Address - Phone:530-966-9198
Mailing Address - Fax:
Practice Address - Street 1:185 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3356
Practice Address - Country:US
Practice Address - Phone:530-332-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95167064163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse