Healthcare Provider Details

I. General information

NPI: 1679619605
Provider Name (Legal Business Name): PATRICIA PICKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 E POPLAR AVE
SELMER TN
38375-1828
US

IV. Provider business mailing address

641 E POPLAR AVE
SELMER TN
38375-1828
US

V. Phone/Fax

Practice location:
  • Phone: 731-645-5753
  • Fax: 731-645-9885
Mailing address:
  • Phone: 731-645-5753
  • Fax: 731-645-9885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: