MEDICARE: SUSAN RENEE HICKS APRN

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	163WC1600X	Continuing Education/Staff Development Registered Nurse	1117248	KY
2	363L00000X	Nurse Practitioner	3012695	KY
3	363LF0000X	Family Nurse Practitioner	3012695	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326541988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN RENEE HICKS APRN

Provider Business Mailing Address
First Line	:	3245 MOUNT MORIAH AVE STE 10
Second Line	:
City	:	OWENSBORO
State	:	KY
Zip	:	42303-7834
Country	:	US
Telephone Number	:	270-663-0955
Fax Number	:	877-466-4151

Provider Business Practice Location Address
First Line	:	2804 FREDERICA STREET
Second Line	:	SUITE 1
City	:	OWENSBORO
State	:	KY
Zip	:	42301-4230
Country	:	US
Telephone Number	:	270-240-3633
Fax Number	:	877-258-2979

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

Provider Enumeration Date	:	03/09/2018
Last Update Date	:	01/24/2022

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Directions to “ SUSAN RENEE HICKS APRN” Practice Location

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