Provider Demographics
NPI:1457879272
Name:HICKS, EPIPHANY
Entity Type:Individual
Prefix:
First Name:EPIPHANY
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 1:1615 NE FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2336
Mailing Address - Country:US
Mailing Address - Phone:503-560-5089
Mailing Address - Fax:
Practice Address - Street 1:945 NW NAITO PKWY APT 535
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-4718
Practice Address - Country:US
Practice Address - Phone:678-933-3944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker