Provider Demographics
NPI:1851588578
Name:HICKS, KATHLEEN A (LPN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
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 1:2673 EGYPT RD
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-9603
Mailing Address - Country:US
Mailing Address - Phone:419-964-0602
Mailing Address - Fax:
Practice Address - Street 1:337 N. EDGEWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:OH
Practice Address - Zip Code:44846
Practice Address - Country:US
Practice Address - Phone:419-499-8310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN126954-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse