Provider Demographics
NPI:1558694240
Name:HICKS, LARISSA JEAN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:JEAN
Last Name:HICKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:LARISSA
Other - Middle Name:JEAN
Other - Last Name:REAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1007 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-1639
Mailing Address - Country:US
Mailing Address - Phone:937-214-6265
Mailing Address - Fax:
Practice Address - Street 1:1007 MAPLE ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-1639
Practice Address - Country:US
Practice Address - Phone:937-541-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN116195164W00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2973206Medicaid