Provider Demographics
NPI:1205135597
Name:HICKS, MARY JANE (LPN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:HICKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 DAVIDSON AVE APT 5E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-4261
Mailing Address - Country:US
Mailing Address - Phone:718-207-6559
Mailing Address - Fax:347-862-4371
Practice Address - Street 1:2506 DAVIDSON AVE
Practice Address - Street 2:5E
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-4258
Practice Address - Country:US
Practice Address - Phone:718-207-6559
Practice Address - Fax:347-862-4371
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280078-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse