Healthcare Provider Details

I. General information

NPI: 1922181973
Provider Name (Legal Business Name): SANDRA E. HICKMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 SUNCREST DR
GRAY TN
37615-4118
US

IV. Provider business mailing address

PO BOX 70403
JOHNSON CITY TN
37614-1703
US

V. Phone/Fax

Practice location:
  • Phone: 423-477-1634
  • Fax:
Mailing address:
  • Phone: 423-439-4078
  • Fax: 423-439-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN5142
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: