Healthcare Provider Details

I. General information

NPI: 1740149335
Provider Name (Legal Business Name): MARLYNN CEREDO HICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 PARK SPRINGS BLVD STE 130
ARLINGTON TX
76017-1935
US

IV. Provider business mailing address

1935 MEDICAL DISTRICT DR
DALLAS TX
75235-7701
US

V. Phone/Fax

Practice location:
  • Phone: 817-960-9120
  • Fax: 817-466-7289
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA20030
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberPA20030
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: