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: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 MAIN STREET
NEW AUGUSTA MS
39462
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-964-8391
  • Fax: 601-964-8393
Mailing address:
  • Phone: 601-545-8700
  • Fax: 601-450-2493

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: