Healthcare Provider Details

I. General information

NPI: 1215289434
Provider Name (Legal Business Name): NAN B HICKS HAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MARY ESTHER BLVD MIRACLE-EAR AT SANTA ROSA MALL
MARY ESTHER FL
32569-1693
US

IV. Provider business mailing address

662 HARBOR BLVD STE 140
DESTIN FL
32541-2473
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-3196
  • Fax: 850-243-8294
Mailing address:
  • Phone: 850-243-3196
  • Fax: 850-243-8294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAS4856
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: