Provider Demographics
NPI:1083113393
Name:HICKMAN, TAMITHA SUE
Entity Type:Individual
Prefix:MS
First Name:TAMITHA
Middle Name:SUE
Last Name:HICKMAN
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 1:775 MANCHESTER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1420
Mailing Address - Country:US
Mailing Address - Phone:260-569-3757
Mailing Address - Fax:
Practice Address - Street 1:775 MANCHESTER AVE STE B
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1420
Practice Address - Country:US
Practice Address - Phone:260-569-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28162999A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily