Provider Demographics
NPI:1790392603
Name:LICATA, MARISA (NP)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:LICATA
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:VENTURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28050 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5919
Mailing Address - Country:US
Mailing Address - Phone:248-229-0183
Mailing Address - Fax:
Practice Address - Street 1:21734 MALDEN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-6041
Practice Address - Country:US
Practice Address - Phone:248-229-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704303831363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily