Provider Demographics
NPI:1477654267
Name:HICKEY, MARYANN (RN, APN)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:HICKEY
Suffix:
Gender:F
Credentials:RN, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 N. PONCE DELEON
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6538
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:
Practice Address - Street 1:2703 PONCE DELEON
Practice Address - Street 2:CVS MINUTE CLINIC
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084
Practice Address - Country:US
Practice Address - Phone:186-638-9272
Practice Address - Fax:401-652-9787
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00074500363LF0000X
FL9370087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily