Provider Demographics
NPI:1497380497
Name:LICCARDO, KATHRYN DELUISE (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:DELUISE
Last Name:LICCARDO
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:LOUISE
Other - Last Name:DELUISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:4095 S LEE ST
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3647
Practice Address - Country:US
Practice Address - Phone:770-932-8519
Practice Address - Fax:770-533-4798
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN223459363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty