Provider Demographics
NPI:1366808735
Name:HICKS, STEPHANIE L (PA-C)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:L
Last Name:HICKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 GOLDENROD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-7665
Mailing Address - Country:US
Mailing Address - Phone:153-424-9018
Mailing Address - Fax:
Practice Address - Street 1:132 GOLDENROD DR
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-7665
Practice Address - Country:US
Practice Address - Phone:815-342-4901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005757363A00000X
FLPA9118138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant