Provider Demographics
NPI:1225795750
Name:HICKS, OCTAVIA ANNESSIA RENEE
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:ANNESSIA RENEE
Last Name:HICKS
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 1:124 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:TEACHEY
Mailing Address - State:NC
Mailing Address - Zip Code:28464-9522
Mailing Address - Country:US
Mailing Address - Phone:910-463-8880
Mailing Address - Fax:
Practice Address - Street 1:124 MAPLE ST
Practice Address - Street 2:
Practice Address - City:TEACHEY
Practice Address - State:NC
Practice Address - Zip Code:28464-9522
Practice Address - Country:US
Practice Address - Phone:910-463-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program