Provider Demographics
NPI:1699989665
Name:HICKMAN, TAMARA LYNN (CPNP)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
Last Name:HICKMAN
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 1:8275 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49622-9701
Mailing Address - Country:US
Mailing Address - Phone:231-544-6960
Mailing Address - Fax:
Practice Address - Street 1:NORTHWEST MICHIGAN COMMUNITY HEALTH AGENCY
Practice Address - Street 2:220 W. GARFIELD STREET
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720
Practice Address - Country:US
Practice Address - Phone:231-547-6523
Practice Address - Fax:231-547-6238
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704113645363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MITH113645OtherBCBSM LICENSE NUMBER
MI4868054Medicaid
MI50-0-A5-1010-0OtherBCBSM