Provider Demographics
NPI:1023379310
Name:HICKS, EXUREPHA BASHAWN (CNA)
Entity Type:Individual
Prefix:MISS
First Name:EXUREPHA
Middle Name:BASHAWN
Last Name:HICKS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 IDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-5825
Mailing Address - Country:US
Mailing Address - Phone:850-341-0361
Mailing Address - Fax:
Practice Address - Street 1:4214 IDLEWOOD DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-5825
Practice Address - Country:US
Practice Address - Phone:850-341-0361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-03
Last Update Date:2012-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL61041172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker