Provider Demographics
NPI:1497333660
Name:HICKMAN, NICOLE (STUDENT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50647-1021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 9TH ST SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2999
Practice Address - Country:US
Practice Address - Phone:319-352-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD174685367500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program