Provider Demographics
NPI:1265106819
Name:HICKS, CORAL NICOLE (MOT)
Entity type:Individual
Prefix:
First Name:CORAL
Middle Name:NICOLE
Last Name:HICKS
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:CORAL
Other - Middle Name:NICOLE
Other - Last Name:RADNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT
Mailing Address - Street 1:30 TAVERNIER DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0677
Mailing Address - Country:US
Mailing Address - Phone:904-404-2345
Mailing Address - Fax:904-789-6295
Practice Address - Street 1:30 TAVERNIER DR UNIT B30
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32081-0677
Practice Address - Country:US
Practice Address - Phone:904-404-2345
Practice Address - Fax:904-789-6295
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21961225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist