Healthcare Provider Details

I. General information

NPI: 1497187330
Provider Name (Legal Business Name): SHANNON NAPUA HICKMAN ROMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP, UNIT 5142
APO AP
96368-9998
US

IV. Provider business mailing address

PSC 80 BOX 14404
APO AP
96367-0047
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.00002109
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: