Provider Demographics
NPI:1568471050
Name:LICARI, KELLY SUE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:LICARI
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1886 KEYSTONE PL
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-3534
Mailing Address - Country:US
Mailing Address - Phone:773-398-2686
Mailing Address - Fax:
Practice Address - Street 1:800 W CENTRAL RD
Practice Address - Street 2:NORTHWEST COMMUNITY HOSPITAL
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2349
Practice Address - Country:US
Practice Address - Phone:847-618-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00398Medicare UPIN
ILK38011Medicare PIN