Provider Demographics
NPI:1417545252
Name:HICKS, IDELLA MARIE
Entity Type:Individual
Prefix:
First Name:IDELLA
Middle Name:MARIE
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 1:4183 WAYLAND CT
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-2818
Mailing Address - Country:US
Mailing Address - Phone:330-951-9865
Mailing Address - Fax:
Practice Address - Street 1:4183 WAYLAND CT
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2818
Practice Address - Country:US
Practice Address - Phone:330-951-9865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness