Healthcare Provider Details

I. General information

NPI: 1083931976
Provider Name (Legal Business Name): TARA J HICKMAN NMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2010
Last Update Date: 05/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3538 N HIGHWAY 112
FAYETTEVILLE AR
72704-5485
US

IV. Provider business mailing address

977 E OAKS MANOR DR
FAYETTEVILLE AR
72703-3519
US

V. Phone/Fax

Practice location:
  • Phone: 479-445-2220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number09-1163
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: