Provider Demographics
NPI:1083931976
Name:HICKMAN, TARA J (NMD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 E OAKS MANOR DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3538 N HIGHWAY 112
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5485
Practice Address - Country:US
Practice Address - Phone:479-445-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-01
Last Update Date:2010-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09-1163175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath