Provider Demographics
NPI:1316797749
Name:HICKS, AUTUMN NATASHA
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NATASHA
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 WILLOW RD W
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1673
Mailing Address - Country:US
Mailing Address - Phone:347-466-2567
Mailing Address - Fax:
Practice Address - Street 1:274 WILLOW RD W
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1673
Practice Address - Country:US
Practice Address - Phone:347-466-2567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF353587-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily