Healthcare Provider Details

I. General information

NPI: 1952004301
Provider Name (Legal Business Name): KATIE MICHELLE HICKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42603 MEADE CIR
TEMECULA CA
92592-8188
US

IV. Provider business mailing address

42603 MEADE CIR
TEMECULA CA
92592-8188
US

V. Phone/Fax

Practice location:
  • Phone: 951-216-8580
  • Fax:
Mailing address:
  • Phone: 951-216-8580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: