Healthcare Provider Details

I. General information

NPI: 1699989665
Provider Name (Legal Business Name): TAMARA LYNN HICKMAN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTHWEST MICHIGAN COMMUNITY HEALTH AGENCY 220 W. GARFIELD STREET
CHARLEVOIX MI
49720
US

IV. Provider business mailing address

8275 W STATE ST
CENTRAL LAKE MI
49622-9701
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-6523
  • Fax: 231-547-6238
Mailing address:
  • Phone: 231-544-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704113645
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: