Provider Demographics
NPI:1770900532
Name:HICKS, KRISTEN (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 BROADMOOR RD
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-8793
Mailing Address - Country:US
Mailing Address - Phone:803-984-4299
Mailing Address - Fax:
Practice Address - Street 1:127 BROADMOOR RD
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-8793
Practice Address - Country:US
Practice Address - Phone:803-984-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC317133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered