Provider Demographics
NPI:1619426319
Name:HICKS, AMANDA LEA (RN)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LEA
Last Name:HICKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEA
Other - Last Name:WOODARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3934 PARK DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-0551
Mailing Address - Country:US
Mailing Address - Phone:605-455-8203
Mailing Address - Fax:605-455-2808
Practice Address - Street 1:1000 HEALTH CENTER ROAD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752
Practice Address - Country:US
Practice Address - Phone:605-455-8203
Practice Address - Fax:605-455-2808
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR047377163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care