Healthcare Provider Details

I. General information

NPI: 1013845502
Provider Name (Legal Business Name): ANGELISE HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 ROSSVILLE AVE
STATEN ISLAND NY
10309-1718
US

IV. Provider business mailing address

655 ROSSVILLE AVE
STATEN ISLAND NY
10309-1718
US

V. Phone/Fax

Practice location:
  • Phone: 718-967-2955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number073919
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: