Healthcare Provider Details

I. General information

NPI: 1649068420
Provider Name (Legal Business Name): LISA A HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S WOOSTER AVE
DOVER OH
44622-1944
US

IV. Provider business mailing address

4600 MONTGOMERY RD STE 400
CINCINNATI OH
45212-2600
US

V. Phone/Fax

Practice location:
  • Phone: 833-510-4357
  • Fax: 866-460-2997
Mailing address:
  • Phone: 833-510-4357
  • Fax: 866-460-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.528761
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: