Healthcare Provider Details

I. General information

NPI: 1114543980
Provider Name (Legal Business Name): MILESTONES PEDIATRIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 S CHURCH ST STE B
BROOKHAVEN MS
39601-3232
US

IV. Provider business mailing address

224 S CHURCH ST STE B
BROOKHAVEN MS
39601-3232
US

V. Phone/Fax

Practice location:
  • Phone: 601-990-4028
  • Fax:
Mailing address:
  • Phone: 601-990-4028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY HATCHER HICKMAN
Title or Position: OWNER
Credential: CPNP
Phone: 601-990-4028