MEDICARE: DESTINY BRIAZIA HICKS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1043877863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY BRIAZIA HICKS

Provider Business Mailing Address
First Line	:	2110 E FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5190
Country	:	US
Telephone Number	:	725-222-7203
Fax Number	:

Provider Business Practice Location Address
First Line	:	5828 RUNNING HORSE DR
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89081-8006
Country	:	US
Telephone Number	:	775-910-3312
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2019
Last Update Date	:	05/28/2019

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Directions to “ DESTINY BRIAZIA HICKS ” Practice Location

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