Healthcare Provider Details

I. General information

NPI: 1356602957
Provider Name (Legal Business Name): DEBORAH S ICKES RN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12503 WILLOWBROOK RD
CUMBERLAND MD
21502-2554
US

IV. Provider business mailing address

PO BOX 1745
CUMBERLAND MD
21501-1745
US

V. Phone/Fax

Practice location:
  • Phone: 301-759-5280
  • Fax: 301-777-5630
Mailing address:
  • Phone: 301-759-5280
  • Fax: 301-777-5630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR170844
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: