MEDICARE: MARJERNELL HICKMAN AGPCNP

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	363LP2300X	Primary Care Nurse Practitioner	95032891	CA

General Provider Information

NPI Number	:	1316753981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARJERNELL HICKMAN AGPCNP

Provider Business Mailing Address
First Line	:	225 PAMELA DR APT 16
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-3235
Country	:	US
Telephone Number	:	803-360-1268
Fax Number	:

Provider Business Practice Location Address
First Line	:	2498 STEVENS CREEK BLVD
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95128-1652
Country	:	US
Telephone Number	:	408-998-5400
Fax Number	:	408-998-5414

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

Provider Enumeration Date	:	12/09/2024
Last Update Date	:	12/09/2024

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