Provider Demographics
NPI:1679096580
Name:LICEA, MARLISIS I (MD)
Entity Type:Individual
Prefix:
First Name:MARLISIS
Middle Name:
Last Name:LICEA
Suffix:I
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10985 SW 107TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-3344
Mailing Address - Country:US
Mailing Address - Phone:305-917-5986
Mailing Address - Fax:
Practice Address - Street 1:10985 SW 107TH ST APT 202
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-3344
Practice Address - Country:US
Practice Address - Phone:786-560-5824
Practice Address - Fax:786-560-5824
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL797763747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant