Provider Demographics
NPI:1265119218
Name:HICKS, KRISTY
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:HICKS
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 1:33942 COUNTY ROUTE 194
Mailing Address - Street 2:
Mailing Address - City:ANTWERP
Mailing Address - State:NY
Mailing Address - Zip Code:13608-3170
Mailing Address - Country:US
Mailing Address - Phone:315-955-5026
Mailing Address - Fax:
Practice Address - Street 1:650 STATE STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1251
Practice Address - Country:US
Practice Address - Phone:315-755-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY847953163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY847953OtherPROFESSIONAL LICENSE