Provider Demographics
NPI:1124354196
Name:FICKLIN, AMY SUZANNE (LPN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUZANNE
Last Name:FICKLIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 NW ADWICK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-9207
Mailing Address - Country:US
Mailing Address - Phone:317-716-8197
Mailing Address - Fax:
Practice Address - Street 1:763 NW ADWICK DRIVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-9207
Practice Address - Country:US
Practice Address - Phone:317-716-8197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200930338LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse