Provider Demographics
NPI:1710538681
Name:HICKERSON, ADRIENE ALISA
Entity type:Individual
Prefix:
First Name:ADRIENE
Middle Name:ALISA
Last Name:HICKERSON
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 1:301 AXIS DR APT 207
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0127
Mailing Address - Country:US
Mailing Address - Phone:502-365-0698
Mailing Address - Fax:
Practice Address - Street 1:301 AXIS DR APT 207
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-0127
Practice Address - Country:US
Practice Address - Phone:502-365-0698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH92436703Other3747A0650X