Provider Demographics
NPI:1609343698
Name:LICKSON, VANESSA GAMMILL (APRN)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:GAMMILL
Last Name:LICKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3409
Mailing Address - Country:US
Mailing Address - Phone:850-747-5599
Mailing Address - Fax:
Practice Address - Street 1:16875 NE CAYSON ST
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-2209
Practice Address - Country:US
Practice Address - Phone:850-674-2244
Practice Address - Fax:850-674-2249
Is Sole Proprietor?:No
Enumeration Date:2018-10-27
Last Update Date:2024-01-03
Deactivation Date:2018-11-14
Deactivation Code:
Reactivation Date:2019-01-08
Provider Licenses
StateLicense IDTaxonomies
FL9301316163W00000X
FL11000074363L00000X
FLAPRN11000074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner