Healthcare Provider Details

I. General information

NPI: 1477888790
Provider Name (Legal Business Name): TRACEY QUAY HICKMAN FNP, APMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2009
Last Update Date: 02/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 FOOTE ST
CORINTH MS
38834-4834
US

IV. Provider business mailing address

601 FOOTE ST
CORINTH MS
38834-4834
US

V. Phone/Fax

Practice location:
  • Phone: 662-287-4424
  • Fax:
Mailing address:
  • Phone: 662-287-4424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR782227
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR782227
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: