Healthcare Provider Details

I. General information

NPI: 1164049029
Provider Name (Legal Business Name): SUSAN JANE NISSON HICKS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN JANE NISSON HICKS NP

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3145 MARSHALL HALL RD
BRYANS ROAD MD
20616-4263
US

IV. Provider business mailing address

900 ELKRIDGE LANDING RD
LINTHICUM HEIGHTS MD
21090-2924
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-5350
  • Fax: 301-684-2134
Mailing address:
  • Phone: 301-609-5350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR091864
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: