Provider Demographics
NPI:1194970160
Name:HICKS, PAMEALLA ANN (LMT)
Entity type:Individual
Prefix:MRS
First Name:PAMEALLA
Middle Name:ANN
Last Name:HICKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DEL PRADO BLVD N
Mailing Address - Street 2:SUITE #101
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-6307
Mailing Address - Country:US
Mailing Address - Phone:239-242-8004
Mailing Address - Fax:239-242-8003
Practice Address - Street 1:19 DEL PRADO BLVD N
Practice Address - Street 2:SUITE #101
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-6307
Practice Address - Country:US
Practice Address - Phone:239-242-8004
Practice Address - Fax:239-242-8003
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47163225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist