Provider Demographics
NPI:1609025253
Name:HICKS, SARA JEANNINE GALE (LPN)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JEANNINE GALE
Last Name:HICKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:JEANNINE
Other - Last Name:GALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2436
Mailing Address - Fax:
Practice Address - Street 1:119 GAS PLANT RD
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-3866
Practice Address - Country:US
Practice Address - Phone:618-542-8702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043101095164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse