1780918037 NPI number — KATHLEEN M HECKEL HICKS FNP-C

Table of content: KATHLEEN M HECKEL HICKS FNP-C (NPI 1780918037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780918037 NPI number — KATHLEEN M HECKEL HICKS FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HECKEL HICKS
Provider First Name:
KATHLEEN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780918037
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86304-0880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-406-4786
Provider Business Mailing Address Fax Number:
916-636-4358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
474 N HWY 89
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHINO VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86323-5993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-636-5680
Provider Business Practice Location Address Fax Number:
928-636-5653
Provider Enumeration Date:
09/18/2009

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:  AP3460 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 983442 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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