Healthcare Provider Details

I. General information

NPI: 1033206545
Provider Name (Legal Business Name): WANDA DENISE HICKS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 VALLIER CT
SATSUMA AL
36572-2832
US

IV. Provider business mailing address

1111 E I65 SERVICE RD S STE 106
MOBILE AL
36606-3101
US

V. Phone/Fax

Practice location:
  • Phone: 251-408-7568
  • Fax: 251-272-3098
Mailing address:
  • Phone: 251-408-7568
  • Fax: 251-272-3098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1090842
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: