Healthcare Provider Details

I. General information

NPI: 1831837244
Provider Name (Legal Business Name): CONSTANCE NICOLE HICKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 HERITAGE VILLAGE PLZ
GAINESVILLE VA
20155-3078
US

IV. Provider business mailing address

22171 BREITLING TER
BROADLANDS VA
20148-4171
US

V. Phone/Fax

Practice location:
  • Phone: 571-248-6100
  • Fax:
Mailing address:
  • Phone: 703-795-5658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: