Provider Demographics
NPI:1518744036
Name:HICKERSON, OPHELIA
Entity Type:Individual
Prefix:
First Name:OPHELIA
Middle Name:
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:MC GRATH
Mailing Address - State:AK
Mailing Address - Zip Code:99627-0238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 DNR ROAD
Practice Address - Street 2:
Practice Address - City:MCGRATH
Practice Address - State:AK
Practice Address - Zip Code:99627
Practice Address - Country:US
Practice Address - Phone:907-524-3299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health