Provider Demographics
NPI:1033759022
Name:HICKS, MALLORY (LPN-MED IV CERTIFIED)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:LPN-MED IV CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 BAYSPIRIT DR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3306 BAYSPIRIT DR
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7086
Practice Address - Country:US
Practice Address - Phone:614-330-1074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.166790.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse