Provider Demographics
NPI:1538833389
Name:HICKEY, BREANNA LAUREN
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:LAUREN
Last Name:HICKEY
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:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-5299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF CENTRAL MISSOURI
Practice Address - Street 2:116 W SOUTH ST
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-5299
Practice Address - Country:US
Practice Address - Phone:877-729-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MO2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty