Healthcare Provider Details

I. General information

NPI: 1063869469
Provider Name (Legal Business Name): AMBER HICKS-THIBODEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

798 OAK RIDGE FARM HWY. SUITE A
MOORESVILLE NC
28115
US

IV. Provider business mailing address

798 OAK RIDGE FARM HWY. SUITE A
MOORESVILLE NC
28115
US

V. Phone/Fax

Practice location:
  • Phone: 704-658-0011
  • Fax: 704-658-0012
Mailing address:
  • Phone: 704-658-0011
  • Fax: 704-658-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015-02105
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: