MEDICARE: MRS. GERALD NICHOLE HICKS LPN

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	164W00000X	Licensed Practical Nurse	LPN081930	GA

General Provider Information

NPI Number	:	1235443169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GERALD NICHOLE HICKS LPN

Provider Business Mailing Address
First Line	:	102 WHITFIELD LN
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-8508
Country	:	US
Telephone Number	:	478-988-1212
Fax Number	:

Provider Business Practice Location Address
First Line	:	940 HIGHWAY 96 STE A
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-2587
Country	:	US
Telephone Number	:	478-988-1212
Fax Number	:

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

Provider Enumeration Date	:	08/03/2010
Last Update Date	:	08/03/2010

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