Provider Demographics
NPI:1417639907
Name:HIVICK, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:HIVICK
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:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:KESWICK
Mailing Address - State:VA
Mailing Address - Zip Code:22947-0265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:534 BEAVER POND RDG
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:VA
Practice Address - Zip Code:22974-3879
Practice Address - Country:US
Practice Address - Phone:434-249-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant