Provider Demographics
NPI:1043017593
Name:HICKS, TECILLA RESHAWN
Entity type:Individual
Prefix:
First Name:TECILLA
Middle Name:RESHAWN
Last Name:HICKS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SE BAYA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6073
Mailing Address - Country:US
Mailing Address - Phone:904-558-1904
Mailing Address - Fax:
Practice Address - Street 1:725 SE BAYA DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6073
Practice Address - Country:US
Practice Address - Phone:904-558-1904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician