Healthcare Provider Details

I. General information

NPI: 1316753981
Provider Name (Legal Business Name): MARJERNELL HICKMAN AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2498 STEVENS CREEK BLVD
SAN JOSE CA
95128-1652
US

IV. Provider business mailing address

225 PAMELA DR APT 16
MOUNTAIN VIEW CA
94040-3235
US

V. Phone/Fax

Practice location:
  • Phone: 408-998-5400
  • Fax: 408-998-5414
Mailing address:
  • Phone: 803-360-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95032891
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: