Provider Demographics
NPI:1669270047
Name:HICKS, TIFFANY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:HICKS
Suffix:
Gender:
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 LAKEWOOD FARMS DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-3169
Mailing Address - Country:US
Mailing Address - Phone:515-835-9045
Mailing Address - Fax:
Practice Address - Street 1:625 LAKEWOOD FARMS DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-3169
Practice Address - Country:US
Practice Address - Phone:515-835-9045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL-311240163W00000X, 163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse