Basic Information
| Provider Information | |||||||||
| NPI: | 1649718271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKMAN | ||||||||
| FirstName: | KATHRYN | ||||||||
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| Credential: | DNP, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6225 N STATE HIGHWAY 161 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750382223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146870001 | ||||||||
| FaxNumber: | 9725182100 | ||||||||
| Practice Location | |||||||||
| Address1: | 6225 N STATE HIGHWAY 161 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750382223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146870001 | ||||||||
| FaxNumber: | 9725182100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2017 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/29/2021 | ||||||||
| NPIReactivationDate: | 04/02/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP133103 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.