MEDICARE: WENDY LOUISE 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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1356934103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY LOUISE HICKS

Provider Business Mailing Address
First Line	:	1 PALM DR
Second Line	:
City	:	BUNNELL
State	:	FL
Zip	:	32110-8437
Country	:	US
Telephone Number	:	307-660-3900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 PALM DR
Second Line	:
City	:	BUNNELL
State	:	FL
Zip	:	32110-8437
Country	:	US
Telephone Number	:	307-660-3900
Fax Number	:

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

Provider Enumeration Date	:	02/12/2021
Last Update Date	:	02/12/2021

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