Provider Demographics
NPI:1235495680
Name:LICINA, LAUREN KEMP (MD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:KEMP
Last Name:LICINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E 68TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:212-746-2959
Mailing Address - Fax:
Practice Address - Street 1:3256 ARDMORE RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44120-3402
Practice Address - Country:US
Practice Address - Phone:216-798-5974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.131366207LP3000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program