Provider Demographics
NPI:1497746622
Name:LICHTY, DEE RAY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DEE
Middle Name:RAY
Last Name:LICHTY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ACORN CT
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5405
Mailing Address - Country:US
Mailing Address - Phone:904-342-0313
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3294872367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA166381711AMedicaid
FL430046091OtherRAILROAD MEDICARE
FLG2350OtherBLUECROSS/BLUESHIELD
FL302804600Medicaid
FLG2350OtherBLUECROSS/BLUESHIELD
FL302804600Medicaid