Provider Demographics
NPI:1497783302
Name:HICKS, TERESA ANNE (RD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANNE
Last Name:HICKS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 DIPLOMACY DR
Mailing Address - Street 2:ATTN: SHERRY REEDY
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5926
Mailing Address - Country:US
Mailing Address - Phone:907-729-3971
Mailing Address - Fax:907-729-1542
Practice Address - Street 1:4315 DIPLOMACY DR
Practice Address - Street 2:ATTN: SHERRY REEDY
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5926
Practice Address - Country:US
Practice Address - Phone:907-729-3971
Practice Address - Fax:907-729-1542
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK95133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDT0095Medicaid