Provider Demographics
NPI:1700070315
Name:HICKEY, CHARLES W (NP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:HICKEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2869
Mailing Address - Country:US
Mailing Address - Phone:540-450-0072
Mailing Address - Fax:540-450-0074
Practice Address - Street 1:1818 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2869
Practice Address - Country:US
Practice Address - Phone:540-450-0072
Practice Address - Fax:540-450-0074
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167461363LF0000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1700070315Medicaid
VAP00657227OtherMEDICARE RR
WV3810009838Medicaid
VAP00657227OtherMEDICARE RR