Provider Demographics
NPI:1568108546
Name:CHANG LICEA, GUILLERMO S (APRN)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:S
Last Name:CHANG LICEA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 WHIPPOORWILL LN
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34105-3800
Mailing Address - Country:US
Mailing Address - Phone:239-285-9046
Mailing Address - Fax:239-332-0407
Practice Address - Street 1:2718 LEE BLVD STE B
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-1537
Practice Address - Country:US
Practice Address - Phone:239-288-0840
Practice Address - Fax:239-244-2195
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty