Provider Demographics
NPI:1205572260
Name:HICKS, QUINTARA (PMHNP)
Entity type:Individual
Prefix:
First Name:QUINTARA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 FOX TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-6147
Mailing Address - Country:US
Mailing Address - Phone:804-370-3783
Mailing Address - Fax:
Practice Address - Street 1:115 ATRIUM WAY BLDG STE 221
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6371
Practice Address - Country:US
Practice Address - Phone:803-699-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001278937363LP0808X
SC26845363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health