Provider Demographics
NPI:1427197888
Name:LICUD, ANNA LISA (ACNP)
Entity Type:Individual
Prefix:MISS
First Name:ANNA LISA
Middle Name:
Last Name:LICUD
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9004 TEDDY RAE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2644
Mailing Address - Country:US
Mailing Address - Phone:571-594-3405
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST., NW
Practice Address - Street 2:WHC SURGICAL CRITICAL CARE SERVICE SUITE 4B-42
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2975
Practice Address - Country:US
Practice Address - Phone:202-877-7259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1003124363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care