Basic Information
| Provider Information | |||||||||
| NPI: | 1265994602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKOX | ||||||||
| FirstName: | BROOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10411 CARDERA DR | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335784072 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1140 KYLE WOOD LN | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335114850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135481009 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2019 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | H220074966840 | 01 | FL | DRIVER'S LICENSE | OTHER |