Provider Demographics
NPI:1922341577
Name:LICATA, ALISSA A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:A
Last Name:LICATA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:ALISSA
Other - Middle Name:A
Other - Last Name:MACCHIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:270 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2787
Mailing Address - Country:US
Mailing Address - Phone:631-796-8444
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1101
Practice Address - Country:US
Practice Address - Phone:516-465-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
NY337734363LF0000X
162005174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
162005OtherIBCLC