Healthcare Provider Details

I. General information

NPI: 1003406067
Provider Name (Legal Business Name): TAMESHIA I HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8036 PHILIPS HWY STE 4
JACKSONVILLE FL
32256-7466
US

IV. Provider business mailing address

1743 CAVALCADE CT
JACKSONVILLE FL
32218-6227
US

V. Phone/Fax

Practice location:
  • Phone: 904-233-5471
  • Fax:
Mailing address:
  • Phone: 904-233-5471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCL1185672
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: