Provider Demographics
NPI:1710221676
Name:RICKS, STEPHANIE (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:RICKS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MEDICAL GROUP
Mailing Address - Street 2:UNIT 5024
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319-5024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3458 NEELY RD
Practice Address - Street 2:
Practice Address - City:JOINT BASE MDL
Practice Address - State:NJ
Practice Address - Zip Code:08641-5312
Practice Address - Country:US
Practice Address - Phone:609-754-9324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX844041363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program