Provider Demographics
NPI:1457626210
Name:HICKMAN, TRACY LYNN (CST, CSFA)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LYNN
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 LEE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6126
Mailing Address - Country:US
Mailing Address - Phone:561-379-8372
Mailing Address - Fax:
Practice Address - Street 1:1717 W WOOLBRIGHT RD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6319
Practice Address - Country:US
Practice Address - Phone:561-737-8031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
107076246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant