Healthcare Provider Details

I. General information

NPI: 1245415397
Provider Name (Legal Business Name): KEVIN LEE HICKEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE MEDICAL VILLAGE DRIVE INDEPENDENT ANESTHESIOLOGISTS PSC
EDGEWOOD KY
41017
US

IV. Provider business mailing address

PO BOX 12749 INDEPENDENT ANESTHESIOLOGISTS PSC
COVINGTON KY
41012-0749
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-7246
  • Fax: 859-341-7867
Mailing address:
  • Phone: 859-341-7246
  • Fax: 859-341-7867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number079098
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1090399
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number262060
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: