Basic Information
Provider Information | |||||||||
NPI: | 1487040820 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HICKEY | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LVNB | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FARLEY | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LVN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1330 N INDIAN CANYON DR | ||||||||
Address2: |   | ||||||||
City: | PALM SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 922624880 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7603229065 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1330 N INDIAN CANYON DR | ||||||||
Address2: |   | ||||||||
City: | PALM SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 922624880 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7603229065 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2015 | ||||||||
LastUpdateDate: | 04/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN235264 | CA | Y |   | Nursing Service Providers | Licensed Vocational Nurse |   |
No ID Information.