Provider Demographics
NPI:1073157459
Name:HICKSON, NICOLE DENISE (NP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DENISE
Last Name:HICKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6507 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21222-4002
Mailing Address - Country:US
Mailing Address - Phone:443-739-3814
Mailing Address - Fax:443-819-1291
Practice Address - Street 1:6507 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-4002
Practice Address - Country:US
Practice Address - Phone:443-760-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR204896363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD666351600Medicaid