Provider Demographics
NPI:1336515808
Name:LICATA, MARYANNA (NP)
Entity Type:Individual
Prefix:MS
First Name:MARYANNA
Middle Name:
Last Name:LICATA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 SOUTHERN DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1237
Mailing Address - Country:US
Mailing Address - Phone:516-526-2623
Mailing Address - Fax:
Practice Address - Street 1:1605 SOUTHERN DR
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-1237
Practice Address - Country:US
Practice Address - Phone:516-526-2623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331097-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily