Provider Demographics
NPI:1780932244
Name:HICKMAN, LISA B (DNP, APRN, CNM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:DNP, APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5077
Mailing Address - Country:US
Mailing Address - Phone:815-226-1172
Mailing Address - Fax:
Practice Address - Street 1:621 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5077
Practice Address - Country:US
Practice Address - Phone:815-226-1172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043-110981164W00000X
IL209028449367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical Nurse