Provider Demographics
NPI:1407980097
Name:HICKEY, DEBRA ANN (CPNP)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:ANN
Last Name:HICKEY
Suffix:
Gender:F
Credentials:CPNP
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 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-638-0150
Mailing Address - Fax:631-638-0157
Practice Address - Street 1:500 COMMACK RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5020
Practice Address - Country:US
Practice Address - Phone:631-638-0150
Practice Address - Fax:631-638-0157
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF380777-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112245457OtherRBK TAX ID#
NY00401381Medicaid