Healthcare Provider Details

I. General information

NPI: 1013284777
Provider Name (Legal Business Name): POLLY ANNE HICKMAN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2669 SCENIC DR
ALAMOGORDO NM
88310-8700
US

IV. Provider business mailing address

2669 SCENIC DR
ALAMOGORDO NM
88310-8700
US

V. Phone/Fax

Practice location:
  • Phone: 575-446-5300
  • Fax: 575-446-5304
Mailing address:
  • Phone: 575-446-5300
  • Fax: 575-446-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-01858
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: