Healthcare Provider Details

I. General information

NPI: 1841470689
Provider Name (Legal Business Name): LINAE MARIE HICKS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 W SAINT GEORGE AVE
GRANTSBURG WI
54840-7827
US

IV. Provider business mailing address

11342 STATE ROAD 48
LUCK WI
54853-9606
US

V. Phone/Fax

Practice location:
  • Phone: 715-463-5353
  • Fax:
Mailing address:
  • Phone: 715-327-5777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number92458-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6772-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: