Provider Demographics
NPI:1649206889
Name:HICKS, STACIE (DO)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W ASH ST
Mailing Address - Street 2:
Mailing Address - City:CONTINENTAL
Mailing Address - State:OH
Mailing Address - Zip Code:45831-9162
Mailing Address - Country:US
Mailing Address - Phone:561-305-9856
Mailing Address - Fax:
Practice Address - Street 1:102 W ASH ST
Practice Address - Street 2:
Practice Address - City:CONTINENTAL
Practice Address - State:OH
Practice Address - Zip Code:45831-9162
Practice Address - Country:US
Practice Address - Phone:419-596-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1588207Q00000X
OH34015494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL296620OtherAVMED
FL7200001OtherAETNA
FL35573OtherBLUE CROSS BLUE SHIELD FL
FL7200001OtherAETNA
FLE2144ZMedicare ID - Type UnspecifiedFLORIDA MEDICARE