Healthcare Provider Details

I. General information

NPI: 1396465621
Provider Name (Legal Business Name): LACY HICKS CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 09/04/2023
Certification Date: 09/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 KNOB CREEK RD STE 208
JOHNSON CITY TN
37604-2367
US

IV. Provider business mailing address

2312 KNOB CREEK RD STE 208
JOHNSON CITY TN
37604-2367
US

V. Phone/Fax

Practice location:
  • Phone: 423-610-1099
  • Fax: 423-246-4300
Mailing address:
  • Phone: 423-610-1099
  • Fax: 423-246-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number1841362555
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: