Individual
JOHNTAVIA K HICKMAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
10471 THORNBERRY DR, SPRING HILL, FL 34608-2829
(414) 930-6176
Mailing address
2120 GWYNHURST BLVD, WESLEY CHAPEL, FL 33543-8101
(414) 930-6176
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
Primary
—
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
862745324
—
FL
Enumeration date
12/21/2021
Last updated
12/21/2021
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