Provider Demographics
NPI:1134536956
Name:HICKS, KIMBERLY LYNN (CNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:HICKS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:GLORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:1075 BEECHER XING N
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-4572
Mailing Address - Country:US
Mailing Address - Phone:614-475-6179
Mailing Address - Fax:614-475-6902
Practice Address - Street 1:1075 BEECHER XING N
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-4572
Practice Address - Country:US
Practice Address - Phone:614-475-6179
Practice Address - Fax:614-475-6902
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRNCNP16141363LF0000X
OHCOA.16141-NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0189940Medicaid