Provider Demographics
NPI:1821724170
Name:HICKS, TIFFANY (LPN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5563 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2225
Mailing Address - Country:US
Mailing Address - Phone:937-291-2300
Mailing Address - Fax:937-291-2303
Practice Address - Street 1:5563 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2225
Practice Address - Country:US
Practice Address - Phone:937-291-2300
Practice Address - Fax:937-291-2303
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH153730164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse