Healthcare Provider Details

I. General information

NPI: 1881775237
Provider Name (Legal Business Name): HENRIETTA HICKS LPN.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 DUPONT HARTSCHAPEL RD.
POPLARVILLE MS
39470-4231
US

IV. Provider business mailing address

50 DUPONT HARTSCHAPEL RD.
POPLARVILLE MS
39470-4231
US

V. Phone/Fax

Practice location:
  • Phone: 601-795-8732
  • Fax: 601-795-8732
Mailing address:
  • Phone: 601-795-8732
  • Fax: 601-795-8732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP245887
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: