Provider Demographics
NPI:1023309200
Name:LICKERMAN, STEPHANIE (APRN, ANP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LICKERMAN
Suffix:
Gender:F
Credentials:APRN, ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SAINT LUKES CENTER DR
Mailing Address - Street 2:STE 303
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3509
Mailing Address - Country:US
Mailing Address - Phone:314-434-3278
Mailing Address - Fax:314-590-5949
Practice Address - Street 1:121 SAINT LUKES CENTER DR
Practice Address - Street 2:STE 303
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3509
Practice Address - Country:US
Practice Address - Phone:314-434-3278
Practice Address - Fax:314-590-5949
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011006713363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4623002Medicare PIN