Provider Demographics
NPI:1912398884
Name:HICKS, CHRISTINE MICHELLE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:MICHELLE
Last Name:HICKS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:MICHELLE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:3459 OLD HALIFAX RD STE I
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-4900
Practice Address - Country:US
Practice Address - Phone:434-549-0383
Practice Address - Fax:434-549-0384
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177743363LA2200X
MDR130205363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health