Provider Demographics
NPI:1821457870
Name:LICKFELDT, KATHLEEN (NP-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:LICKFELDT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 W CHESTER PIKE STE 160
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-7400
Practice Address - Country:US
Practice Address - Phone:484-476-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9288359363LA2200X
PASP029917363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025086800Medicaid
FLV68RYOtherBLUE CROSS