Provider Demographics
NPI:1831113711
Name:HICKS, MARY LOU (NP)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 ARROYO RD
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-9650
Mailing Address - Country:US
Mailing Address - Phone:925-373-4700
Mailing Address - Fax:925-449-6525
Practice Address - Street 1:4951 ARROYO RD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-9650
Practice Address - Country:US
Practice Address - Phone:925-373-4700
Practice Address - Fax:925-449-6525
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA186774363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner