MEDICARE: KEYONA NICOLE HICKS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	P23928	NC

General Provider Information

NPI Number	:	1740087709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEYONA NICOLE HICKS

Provider Business Mailing Address
First Line	:	100 KIMEL FOREST DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6074
Country	:	US
Telephone Number	:	336-713-0947
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 N CHURCH ST STE 230
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27405-5633
Country	:	US
Telephone Number	:	336-275-1711
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2025
Last Update Date	:	05/07/2026

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