Provider Demographics
NPI:1003972274
Name:HICKS, CANDIS M (CNM)
Entity Type:Individual
Prefix:
First Name:CANDIS
Middle Name:M
Last Name:HICKS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CANDIS
Other - Middle Name:M
Other - Last Name:PANNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1300 W TERRELL AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2822
Mailing Address - Country:US
Mailing Address - Phone:817-250-7360
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE STE 320
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2822
Practice Address - Country:US
Practice Address - Phone:817-250-7360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP111164367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195670801Medicaid
TX842134OtherBCBS
TX195670801Medicaid