Provider Demographics
NPI:1710494117
Name:HICKS, LYDIA ELLEN (RN)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:ELLEN
Last Name:HICKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:LYDIA
Other - Middle Name:ELLEN
Other - Last Name:BOYCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1443 WINDING WAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188
Mailing Address - Country:US
Mailing Address - Phone:615-275-5214
Mailing Address - Fax:
Practice Address - Street 1:214 W. LONGVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148
Practice Address - Country:US
Practice Address - Phone:615-325-5237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000183239163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health