Provider Demographics
NPI:1588991533
Name:HICKS, AMY J (APRN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:HICKS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:PETROSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9722
Mailing Address - Fax:239-343-9725
Practice Address - Street 1:4761 S CLEVELAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1375
Practice Address - Country:US
Practice Address - Phone:239-343-9722
Practice Address - Fax:239-343-9725
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9300175363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001641700Medicaid