1992043863 NPI number — HILARY ANN LICARDI ARNP

Table of content: HILARY ANN LICARDI ARNP (NPI 1992043863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992043863 NPI number — HILARY ANN LICARDI ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LICARDI
Provider First Name:
HILARY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEHOSSON
Provider Other First Name:
HILARY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992043863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORVALLIS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97339-1189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 EVERGREEN PL SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-812-4662
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  ARNP2129202 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003131385A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008451000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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