Provider Demographics
NPI:1649418971
Name:HICKS, CONNIE FAIRLEY (DNP-NP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:FAIRLEY
Last Name:HICKS
Suffix:
Gender:F
Credentials:DNP-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 LAKE BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-2934
Mailing Address - Country:US
Mailing Address - Phone:919-856-8710
Mailing Address - Fax:919-256-0772
Practice Address - Street 1:3801 LAKE BOONE TRL
Practice Address - Street 2:SUITE G
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2934
Practice Address - Country:US
Practice Address - Phone:919-865-8710
Practice Address - Fax:919-256-0772
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004262363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner