Provider Demographics
NPI:1184384984
Name:HICKMAN, JOHNTAVIA K
Entity type:Individual
Prefix:
First Name:JOHNTAVIA
Middle Name:K
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 GWYNHURST BLVD
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-8101
Mailing Address - Country:US
Mailing Address - Phone:414-930-6176
Mailing Address - Fax:
Practice Address - Street 1:10471 THORNBERRY DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-2829
Practice Address - Country:US
Practice Address - Phone:414-930-6176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL862745324Medicaid