Provider Demographics
NPI:1639657448
Name:HICKS, KRISTA (RN)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 N 65TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2033
Mailing Address - Country:US
Mailing Address - Phone:414-454-0635
Mailing Address - Fax:
Practice Address - Street 1:2255 N 65TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2033
Practice Address - Country:US
Practice Address - Phone:414-454-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI190273163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse