Healthcare Provider Details

I. General information

NPI: 1720759715
Provider Name (Legal Business Name): KIM FRANCES HICKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 S US HIGHWAY 1
PORT ST LUCIE FL
34952-6407
US

IV. Provider business mailing address

10850 S US HIGHWAY 1
PORT ST LUCIE FL
34952-6407
US

V. Phone/Fax

Practice location:
  • Phone: 777-724-6304
  • Fax: 772-219-1339
Mailing address:
  • Phone: 777-724-6304
  • Fax: 772-219-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: