Healthcare Provider Details

I. General information

NPI: 1497468185
Provider Name (Legal Business Name): MARIETTA MARIE HICKMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37706 RED ROBIN RD
MURRIETA CA
92563-4758
US

IV. Provider business mailing address

37706 RED ROBIN RD
MURRIETA CA
92563-4758
US

V. Phone/Fax

Practice location:
  • Phone: 951-837-5200
  • Fax:
Mailing address:
  • Phone: 951-837-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License Number95068429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: