Healthcare Provider Details

I. General information

NPI: 1194846436
Provider Name (Legal Business Name): LATOYA LANETTE HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S LAUREL ST
PINE BLUFF AR
71601-4859
US

IV. Provider business mailing address

7700 N CHICOT RD APT C202
LITTLE ROCK AR
72209-3785
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-4900
  • Fax:
Mailing address:
  • Phone: 501-837-6115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: