1134536956 NPI number — KIMBERLY LYNN HICKS CNP

Table of content: KIMBERLY LYNN HICKS CNP (NPI 1134536956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134536956 NPI number — KIMBERLY LYNN HICKS CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKS
Provider First Name:
KIMBERLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLORE
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134536956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1075 BEECHER XING N
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43230-4572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-475-6179
Provider Business Mailing Address Fax Number:
614-475-6902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 BEECHER XING N
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43230-4572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-475-6179
Provider Business Practice Location Address Fax Number:
614-475-6902
Provider Enumeration Date:
07/14/2014

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:  APRNCNP16141 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0189940 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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