Provider Demographics
NPI:1447241229
Name:HICKS, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28690 OLD NORTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-1619
Mailing Address - Country:US
Mailing Address - Phone:586-801-8488
Mailing Address - Fax:586-228-4520
Practice Address - Street 1:1 FORD PL
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:800-653-6568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704154971363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447241229Medicaid