Basic Information
| Provider Information | |||||||||
| NPI: | 1538199534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICAVOLI | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | SUSANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSN, APRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 603 CAPTAIN JOHN BRICE WAY | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214016327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138192541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 N GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 4704185653 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | R189866 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.