Healthcare Provider Details

I. General information

NPI: 1114359247
Provider Name (Legal Business Name): SHAUNA HICKEM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N GARTH AVE
COLUMBIA MO
65203-4105
US

IV. Provider business mailing address

201 N GARTH AVE
COLUMBIA MO
65203-4105
US

V. Phone/Fax

Practice location:
  • Phone: 573-449-3953
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number2013019513
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: