Provider Demographics
NPI:1184665366
Name:HICKS, DEBORAH CORNWALL (MED, RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:CORNWALL
Last Name:HICKS
Suffix:
Gender:F
Credentials:MED, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-7170
Mailing Address - Country:US
Mailing Address - Phone:336-472-3581
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-713-3043
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2993742Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NCQ18763Medicare UPIN