Provider Demographics
NPI:1104688274
Name:HICKMAN, ROSA (NP)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 S 11TH ST STE 135
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7157
Mailing Address - Country:US
Mailing Address - Phone:208-367-0700
Mailing Address - Fax:
Practice Address - Street 1:403 S 11TH ST STE 135
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7157
Practice Address - Country:US
Practice Address - Phone:208-367-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID78182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily