Provider Demographics
NPI:1679919682
Name:HICKMAN, TINA RACHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:RACHELLE
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:APRN
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 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:320 E 8TH ST
Practice Address - Street 2:SUITE 142
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3382
Practice Address - Country:US
Practice Address - Phone:740-373-4111
Practice Address - Fax:740-373-4860
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV77927363L00000X
OHAPRN.CNP.16945363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085813Medicaid
WV3810026276Medicaid
OHP01490747OtherRAILROAD MHCPI
WV3810026276Medicaid
OHH445880Medicare PIN