Provider Demographics
NPI:1528631538
Name:HICKS, MIRANDA SUE (NP-C)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SUE
Last Name:HICKS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 HIGHWAY 45 BYP STE 604
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4403
Mailing Address - Country:US
Mailing Address - Phone:731-660-7971
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:367 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2080
Practice Address - Country:US
Practice Address - Phone:731-541-6834
Practice Address - Fax:731-541-7967
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily