Provider Demographics
NPI:1477015691
Name:HICKMAN, KELSEY BRIANNE (PHARMD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:BRIANNE
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 FAIRLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-7026
Mailing Address - Country:US
Mailing Address - Phone:419-496-9693
Mailing Address - Fax:
Practice Address - Street 1:770 BALGREEN DR STE 104
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4106
Practice Address - Country:US
Practice Address - Phone:419-526-8972
Practice Address - Fax:419-529-8974
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03135613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist