Healthcare Provider Details

I. General information

NPI: 1467137455
Provider Name (Legal Business Name): DE ANNA NAKIA HICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CHURCH ST
PHILADELPHIA PA
19106-2201
US

IV. Provider business mailing address

325 W SECOND ST APT A
MEDIA PA
19063-2301
US

V. Phone/Fax

Practice location:
  • Phone: 863-370-6344
  • Fax:
Mailing address:
  • Phone: 610-883-7635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: