Provider Demographics
NPI:1922399286
Name:HICKMAN, HEATHER RENEE (CPNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEE
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:RENEE
Other - Last Name:VANOVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:85 JOHN MADDOX DRIVE CONNECTOR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1233
Practice Address - Country:US
Practice Address - Phone:762-235-2990
Practice Address - Fax:706-238-8031
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN194193363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003108522AMedicaid
GA003108522AMedicaid