Provider Demographics
NPI:1396332573
Name:HICKS, NICOLE LYNN
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
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 1:716 WAYFIELD CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45430-1476
Mailing Address - Country:US
Mailing Address - Phone:937-304-5163
Mailing Address - Fax:
Practice Address - Street 1:716 WAYFIELD CT
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45430-1476
Practice Address - Country:US
Practice Address - Phone:937-304-5163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No374J00000XNursing Service Related ProvidersDoula
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2904842Medicaid