=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518476803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN CAROL HICKMAN RRT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2017
-----------------------------------------------------
Last Update Date | 09/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1589 CR 2954
-----------------------------------------------------
City | ALBA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-474-7210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 308
-----------------------------------------------------
City | GOLDEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75444-0308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-474-7210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 227900000X
-----------------------------------------------------
Taxonomy Name | Registered Respiratory Therapist
-----------------------------------------------------
License Number | RCP00076257
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------