Provider Demographics
NPI:1982427381
Name:HICKSON, LYDIA ROSE
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:ROSE
Last Name:HICKSON
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 1:562 ELM ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3023
Mailing Address - Country:US
Mailing Address - Phone:607-269-6244
Mailing Address - Fax:
Practice Address - Street 1:310 FLORAL AVE APT 502
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5056
Practice Address - Country:US
Practice Address - Phone:607-592-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY347486164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse