Healthcare Provider Details

I. General information

NPI: 1417956897
Provider Name (Legal Business Name): DIANNA LYNN HICKMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNN CARGILL-HICKMAN M.D.

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 WORNALL RD
KANSAS CITY MO
64111-3220
US

IV. Provider business mailing address

901 E 104TH ST MAILSTOP 400S
KANSAS CITY MO
64131-4517
US

V. Phone/Fax

Practice location:
  • Phone: 816-932-3584
  • Fax: 813-932-5873
Mailing address:
  • Phone: 816-599-9499
  • Fax: 816-932-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number107834
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberG03803
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: