Provider Demographics
NPI:1396465621
Name:HICKS, LACY (CPNP)
Entity type:Individual
Prefix:MRS
First Name:LACY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 KNOB CREEK RD STE 208
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2367
Mailing Address - Country:US
Mailing Address - Phone:423-610-1099
Mailing Address - Fax:423-246-4300
Practice Address - Street 1:2312 KNOB CREEK RD STE 208
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2367
Practice Address - Country:US
Practice Address - Phone:423-610-1099
Practice Address - Fax:423-246-4300
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18413625552080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376533489OtherNPI
1578856985OtherNPI