Provider Demographics
NPI:1609441997
Name:HICKMAN, MELISSA LAUREN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LAUREN
Last Name:HICKMAN
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 692
Mailing Address - Street 2:
Mailing Address - City:BOKCHITO
Mailing Address - State:OK
Mailing Address - Zip Code:74726-0692
Mailing Address - Country:US
Mailing Address - Phone:580-364-2980
Mailing Address - Fax:
Practice Address - Street 1:227 SOUTH SMITH STREET
Practice Address - Street 2:
Practice Address - City:BENNINGOTN
Practice Address - State:OK
Practice Address - Zip Code:74723-7472
Practice Address - Country:US
Practice Address - Phone:580-364-2980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program