Provider Demographics
NPI:1104692664
Name:LICA, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LICA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14051 BEACH BLVD APT 4212
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-1837
Mailing Address - Country:US
Mailing Address - Phone:734-649-3280
Mailing Address - Fax:
Practice Address - Street 1:3900 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4331
Practice Address - Country:US
Practice Address - Phone:904-222-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant