Individual
DR. NERISSA LICUP
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
2205 PAVILION DR STE 101, KINGSPORT, TN 37660-4641
(423) 392-6000
(423) 392-6030
Mailing address
1021 W OAKLAND AVE STE 310, JOHNSON CITY, TN 37604-2192
(423) 302-6565
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
46416
TN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1521020
—
TN
05
—
1720269731
—
VA
01
—
4276956
BLUECARE
TN
01
—
P01015971
RR MEDICARE
TN
Enumeration date
11/19/2007
Last updated
06/10/2024
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