Provider Demographics
NPI:1548532393
Name:PHILLIPS-HICKMAN, GLENDA N/A (LPN)
Entity type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:N/A
Last Name:PHILLIPS-HICKMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 SLATE RD
Mailing Address - Street 2:
Mailing Address - City:CANDOR
Mailing Address - State:NY
Mailing Address - Zip Code:13743-1718
Mailing Address - Country:US
Mailing Address - Phone:607-659-3839
Mailing Address - Fax:
Practice Address - Street 1:700 WASHBURN RD
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:NY
Practice Address - Zip Code:14883-9409
Practice Address - Country:US
Practice Address - Phone:607-607-5897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09277-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse