Provider Demographics
NPI:1821342833
Name:LICKERS, DENISE (LPN)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:LICKERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-1918
Mailing Address - Country:US
Mailing Address - Phone:716-563-2287
Mailing Address - Fax:
Practice Address - Street 1:484 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-1918
Practice Address - Country:US
Practice Address - Phone:716-563-2287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205037-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse