=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447428925
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHERYL B. HICKETHIER, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2008
-----------------------------------------------------
Last Update Date | 09/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14831 SE 82ND DR
-----------------------------------------------------
City | CLACKAMAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-7624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-656-5657
-----------------------------------------------------
Fax | 503-656-5658
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14831 SE 82ND DR
-----------------------------------------------------
City | CLACKAMAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-7624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-656-5657
-----------------------------------------------------
Fax | 503-656-5658
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHERYL HICKETHIER
-----------------------------------------------------
Credential | MD, MPH
-----------------------------------------------------
Telephone | 503-656-5657
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD15365
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------