Provider Demographics
NPI:1518790401
Name:HICKS, TAMYRA
Entity type:Individual
Prefix:
First Name:TAMYRA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 GROVE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-5644
Mailing Address - Country:US
Mailing Address - Phone:773-969-1793
Mailing Address - Fax:
Practice Address - Street 1:114 N MARION ST STE 206
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1005
Practice Address - Country:US
Practice Address - Phone:224-477-3796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier