Healthcare Provider Details

I. General information

NPI: 1235599515
Provider Name (Legal Business Name): CHARLENE HICKS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 EDMOND LN
LEAKESVILLE MS
39451-5706
US

IV. Provider business mailing address

PO BOX 16285
HATTIESBURG MS
39404-6285
US

V. Phone/Fax

Practice location:
  • Phone: 601-394-4135
  • Fax:
Mailing address:
  • Phone: 601-318-0669
  • Fax: 601-994-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901452
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: