Provider Demographics
NPI:1164561304
Name:HICKSON, MARIANA C (LPN)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:C
Last Name:HICKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 382
Mailing Address - Street 2:
Mailing Address - City:BOLTON LANDING
Mailing Address - State:NY
Mailing Address - Zip Code:12814-0382
Mailing Address - Country:US
Mailing Address - Phone:518-644-2436
Mailing Address - Fax:
Practice Address - Street 1:12 PETRA LN
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4973
Practice Address - Country:US
Practice Address - Phone:518-452-0445
Practice Address - Fax:518-452-3489
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063793-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY063793-1OtherLPN LICENSE