Healthcare Provider Details

I. General information

NPI: 1750228565
Provider Name (Legal Business Name): CAROLYN JEAN HICKS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18877 JEB STUART HWY
STUART VA
24171-5223
US

IV. Provider business mailing address

1323 MAPLE SHADE RD
LAUREL FORK VA
24352-3851
US

V. Phone/Fax

Practice location:
  • Phone: 276-694-4466
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0024197007
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: