Basic Information
| Provider Information | |||||||||
| NPI: | 1497256671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKMAN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | CATHERINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 BIRCH ST | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767051902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543665995 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1314 LAKE ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178100660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 805993 | TX | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 163WOOOOOX | 01 | TX | RN TAXONOMY CODE | OTHER | 164XOOOOOX | 01 | TX | LVN TAXONOMY CODE | OTHER |