Healthcare Provider Details

I. General information

NPI: 1982530192
Provider Name (Legal Business Name): MRS. LYDIA J MOORE-HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 124
MALTA MT
59538-0124
US

IV. Provider business mailing address

PO BOX 124
MALTA MT
59538-0124
US

V. Phone/Fax

Practice location:
  • Phone: 520-403-1618
  • Fax:
Mailing address:
  • Phone: 520-403-1618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number218759
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: