Provider Demographics
NPI:1356729024
Name:HICKLE, SHANNA (LAC)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:HICKLE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E SUL ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:TX
Mailing Address - Zip Code:79830-4723
Mailing Address - Country:US
Mailing Address - Phone:432-837-3225
Mailing Address - Fax:
Practice Address - Street 1:303 E SUL ROSS AVE
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-4723
Practice Address - Country:US
Practice Address - Phone:432-837-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00490171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist