Provider Demographics
NPI:1184973109
Name:STEVENS, JOHNNA HICKS (MD)
Entity type:Individual
Prefix:
First Name:JOHNNA
Middle Name:HICKS
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOHNNA
Other - Middle Name:RENEE
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:955 RIBAUT RD
Mailing Address - Street 2:BMAC CREDENTIALING
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5441
Mailing Address - Country:US
Mailing Address - Phone:843-522-7843
Mailing Address - Fax:843-522-5678
Practice Address - Street 1:BEAUFORT MEMORIAL BLUFFTON PRIMARY CARE
Practice Address - Street 2:11 ARLEY WAY, STE 201
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-4883
Practice Address - Country:US
Practice Address - Phone:843-706-8690
Practice Address - Fax:844-295-9802
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA78307207R00000X
SC81571207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC81571OtherSTATE LICENSE BOARD
SC815719Medicaid