Provider Demographics
NPI:1104976885
Name:LICCIARDI, KIMBERLY ANN (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:LICCIARDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:TRUAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:764 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-5210
Mailing Address - Country:US
Mailing Address - Phone:603-669-3925
Mailing Address - Fax:
Practice Address - Street 1:764 2ND ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-5210
Practice Address - Country:US
Practice Address - Phone:603-669-3925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188086208600000X
390200000X
NH14856207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program