Provider Demographics
NPI:1902864564
Name:LICINI, DENISE HELEN (NP)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:HELEN
Last Name:LICINI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 GRANITE RAPIDS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-7529
Mailing Address - Country:US
Mailing Address - Phone:862-228-0578
Mailing Address - Fax:
Practice Address - Street 1:6827 W TROPICANA AVE STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4920
Practice Address - Country:US
Practice Address - Phone:702-508-9128
Practice Address - Fax:702-302-4125
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNC085069363LA2200X
CANPF21784363L00000X
NVAPRN822758363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21784OtherNP
CA818601OtherRN
CAHD702ZOtherMEDICARE PTAN