Basic Information
| Provider Information | |||||||||
| NPI: | 1699081372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKMOND | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LYTTON | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19527 HOLLYGRAPE ST | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977022914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413899284 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1247 NE MEDICAL CENTER DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977013786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413184249 | ||||||||
| FaxNumber: | 5413883832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2010 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 080046486N7 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.