Provider Demographics
NPI:1962987511
Name:TRICE-BICKHAM, LYNETTA (APRN FNP-BC)
Entity type:Individual
Prefix:
First Name:LYNETTA
Middle Name:
Last Name:TRICE-BICKHAM
Suffix:
Gender:F
Credentials:APRN FNP-BC
Other - Prefix:
Other - First Name:LYNETTA
Other - Middle Name:F
Other - Last Name:TRICE- BICKHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN FNP-BC
Mailing Address - Street 1:2405 ESSINGTON RD
Mailing Address - Street 2:SUITE B #64
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3814
Practice Address - Country:US
Practice Address - Phone:000-123-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-29
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily