Provider Demographics
NPI:1720269731
Name:LICUP, NERISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:NERISSA
Middle Name:
Last Name:LICUP
Suffix:
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 1:2205 PAVILION DR STE 101
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4641
Mailing Address - Country:US
Mailing Address - Phone:423-392-6000
Mailing Address - Fax:423-392-6030
Practice Address - Street 1:2205 PAVILION DR STE 101
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4641
Practice Address - Country:US
Practice Address - Phone:423-392-6000
Practice Address - Fax:423-392-6030
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN46416207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01015971OtherRR MEDICARE
TN1521020Medicaid
VA1720269731Medicaid
TN4276956OtherBLUECARE
TN4276956OtherBLUECARE
TN1521020Medicaid