Provider Demographics
NPI:1326541988
Name:HICKS, SUSAN RENEE (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:HICKS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 MOUNT MORIAH AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7834
Mailing Address - Country:US
Mailing Address - Phone:270-663-0955
Mailing Address - Fax:877-466-4151
Practice Address - Street 1:2804 FREDERICA STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4230
Practice Address - Country:US
Practice Address - Phone:270-240-3633
Practice Address - Fax:877-258-2979
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1117248163WC1600X
KY3012695363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff DevelopmentGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100561170Medicaid