Provider Demographics
NPI:1811203953
Name:CASSANDRA GIBBS HICKS ARNP LLC
Entity Type:Organization
Organization Name:CASSANDRA GIBBS HICKS ARNP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:772-216-6750
Mailing Address - Street 1:1680 SE LYNGATE DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4300
Mailing Address - Country:US
Mailing Address - Phone:772-335-9808
Mailing Address - Fax:772-335-9818
Practice Address - Street 1:1680 SE LYNGATE DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4300
Practice Address - Country:US
Practice Address - Phone:772-335-9808
Practice Address - Fax:772-335-9818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9275760363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDP044AMedicare PIN
FLDO640ZMedicare PIN