Healthcare Provider Details

I. General information

NPI: 1508233743
Provider Name (Legal Business Name): RYAN TRISTINE HICKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1052 MAIN ST NE STE D
LOS LUNAS NM
87031-7436
US

IV. Provider business mailing address

1052 MAIN ST NE STE D
LOS LUNAS NM
87031-7436
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4140
  • Fax: 505-865-4938
Mailing address:
  • Phone: 505-865-4140
  • Fax: 505-865-4938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: