Provider Demographics
NPI:1811415474
Name:HICKS, MARY KATHERINE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:HICKS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3113
Mailing Address - Country:US
Mailing Address - Phone:734-682-3309
Mailing Address - Fax:734-682-1488
Practice Address - Street 1:1030 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3113
Practice Address - Country:US
Practice Address - Phone:734-682-3309
Practice Address - Fax:734-682-1488
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704140648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily