Provider Demographics
NPI:1386809150
Name:HICKAM, DARLENE MAY (CRNA)
Entity type:Individual
Prefix:
First Name:DARLENE
Middle Name:MAY
Last Name:HICKAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DARLENE
Other - Middle Name:MAY
Other - Last Name:HALLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:92 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:321-841-4607
Mailing Address - Fax:321-841-4603
Practice Address - Street 1:92 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:321-841-4607
Practice Address - Fax:321-841-4603
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN99591163W00000X
TNAPN13589367500000X
FLARNP9332014367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00739761OtherRAILROAD MEDICARE
FL004304300Medicaid
GA495491926AMedicaid
FLARNP9332014OtherMEDICAL LICENSE
TN1509500Medicaid
TN4194192OtherBLUE CROSS BLUE SHIELD TN
GAN473106OtherWELLCARE (GA MEDICAID)
NC8053485Medicaid
AL108054Medicaid
NC8053485Medicaid
TNP00739761OtherRAILROAD MEDICARE