Healthcare Provider Details

I. General information

NPI: 1366808735
Provider Name (Legal Business Name): STEPHANIE L HICKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 02/25/2024
Certification Date: 02/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 GOLDENROD DR
SAINT AUGUSTINE FL
32092-7665
US

IV. Provider business mailing address

132 GOLDENROD DR
SAINT AUGUSTINE FL
32092-7665
US

V. Phone/Fax

Practice location:
  • Phone: 815-342-4901
  • Fax:
Mailing address:
  • Phone: 153-424-9018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.005757
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118138
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: