Basic Information
Provider Information | |||||||||
NPI: | 1356444509 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LICATA | ||||||||
FirstName: | ANITA | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LICATA | ||||||||
OtherFirstName: | ANITA | ||||||||
OtherMiddleName: | GOODRICH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 354 MOUNTAIN VIEW DRIVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | COLCHESTER | ||||||||
State: | VT | ||||||||
PostalCode: | 054465988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8026588624 | ||||||||
FaxNumber: | 8028604919 | ||||||||
Practice Location | |||||||||
Address1: | 354 MOUNTAIN VIEW DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | COLCHESTER | ||||||||
State: | VT | ||||||||
PostalCode: | 054465988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028640192 | ||||||||
FaxNumber: | 8028604919 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2006 | ||||||||
LastUpdateDate: | 09/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 042-0008753 | VT | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.