Provider Demographics
NPI:1528317054
Name:HICKLE, MIRANDA (FNP)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:HICKLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 E HIGHWAY 11 E
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-4910
Mailing Address - Country:US
Mailing Address - Phone:865-375-6005
Mailing Address - Fax:865-471-0244
Practice Address - Street 1:1059 E HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-4910
Practice Address - Country:US
Practice Address - Phone:865-375-6005
Practice Address - Fax:865-471-0244
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16752363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530430Medicaid
TN1035I07695Medicare PIN