Provider Demographics
NPI:1215289434
Name:HICKS, NAN B (HAS)
Entity type:Individual
Prefix:MS
First Name:NAN
Middle Name:B
Last Name:HICKS
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 HARBOR BLVD
Mailing Address - Street 2:STE 140
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2473
Mailing Address - Country:US
Mailing Address - Phone:850-243-3196
Mailing Address - Fax:850-243-8294
Practice Address - Street 1:300 MARY ESTHER BLVD
Practice Address - Street 2:MIRACLE-EAR AT SANTA ROSA MALL
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1693
Practice Address - Country:US
Practice Address - Phone:850-243-3196
Practice Address - Fax:850-243-8294
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4856237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter