Healthcare Provider Details

I. General information

NPI: 1154961209
Provider Name (Legal Business Name): LISA A HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17177 N LAUREL PARK DR STE 417
LIVONIA MI
48152-3952
US

IV. Provider business mailing address

23576 CLINTON ST
TAYLOR MI
48180-4157
US

V. Phone/Fax

Practice location:
  • Phone: 888-414-7056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703120442
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: