Provider Demographics
NPI:1407531098
Name:LICURSI, KELLI ANN (764981: RN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:LICURSI
Suffix:
Gender:F
Credentials:764981: RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 HICKORY HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-2628
Mailing Address - Country:US
Mailing Address - Phone:914-482-2388
Mailing Address - Fax:
Practice Address - Street 1:41 E POST RD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-4699
Practice Address - Country:US
Practice Address - Phone:914-482-2388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY764981163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse