Provider Demographics
NPI:1255405353
Name:HICKS-MASTER, ANGIE D (ANP)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:D
Last Name:HICKS-MASTER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 717
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442
Mailing Address - Country:US
Mailing Address - Phone:870-570-0358
Mailing Address - Fax:870-570-0359
Practice Address - Street 1:920 EAST MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442
Practice Address - Country:US
Practice Address - Phone:810-570-0358
Practice Address - Fax:870-570-0359
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA002923363LP0808X
TNAPN0000017515363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2007012778OtherMO STATE LICENSE
ARA002923OtherAR STATE LICENSE
TN17515OtherTN STATE LICENSE