Healthcare Provider Details

I. General information

NPI: 1427643261
Provider Name (Legal Business Name): ODESHA HICKMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 FORTY MILE AVE
FAIRBANKS AK
99701-3110
US

IV. Provider business mailing address

209 FORTY MILE AVE
FAIRBANKS AK
99701-3110
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-6445
  • Fax:
Mailing address:
  • Phone: 907-456-6445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: